step3/content/repairs/wrong-answer-followups-20260801.json

{
  "batchId": "wrong-answer-followups-20260801",
  "createdUtc": "2026-08-01T22:19:54.1660489Z",
  "entries": [
    {
      "externalId": "d5-allergy-beta-blocker-refractory-anaphylaxis-glucagon-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "28ed1470194d0f1cb527bb299757d3426e9832666ece13424530d13db5ed28ac",
        "ranaze_step3_prd": "28ed1470194d0f1cb527bb299757d3426e9832666ece13424530d13db5ed28ac"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Atropine as the sole remaining treatment is inappropriate because atropine may raise heart rate but does not adequately treat refractory anaphylactic shock."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous diphenhydramine is inappropriate because antihistamine treats cutaneous symptoms, not refractory circulatory collapse."
            },
            {
              "id": "C",
              "text": "Option D: Subcutaneous terbutaline as monotherapy is inappropriate because a beta agonist may also be blunted and cannot replace systemic resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Atropine as the sole remaining treatment is inappropriate because atropine may raise heart rate but does not adequately treat refractory anaphylactic shock."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous diphenhydramine is inappropriate because antihistamine treats cutaneous symptoms, not refractory circulatory collapse."
            },
            {
              "id": "B",
              "text": "Option A: Atropine as the sole remaining treatment is inappropriate because atropine may raise heart rate but does not adequately treat refractory anaphylactic shock."
            },
            {
              "id": "C",
              "text": "Option D: Subcutaneous terbutaline as monotherapy is inappropriate because a beta agonist may also be blunted and cannot replace systemic resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous diphenhydramine is inappropriate because antihistamine treats cutaneous symptoms, not refractory circulatory collapse."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcutaneous terbutaline as monotherapy is inappropriate because a beta agonist may also be blunted and cannot replace systemic resuscitation."
            },
            {
              "id": "B",
              "text": "Option A: Atropine as the sole remaining treatment is inappropriate because atropine may raise heart rate but does not adequately treat refractory anaphylactic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous diphenhydramine is inappropriate because antihistamine treats cutaneous symptoms, not refractory circulatory collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcutaneous terbutaline as monotherapy is inappropriate because a beta agonist may also be blunted and cannot replace systemic resuscitation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Protamine sulfate is inappropriate because protamine reverses heparin and has no role in contrast anaphylaxis."
            },
            {
              "id": "B",
              "text": "Option A: Atropine as the sole remaining treatment is inappropriate because atropine may raise heart rate but does not adequately treat refractory anaphylactic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous diphenhydramine is inappropriate because antihistamine treats cutaneous symptoms, not refractory circulatory collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Protamine sulfate is inappropriate because protamine reverses heparin and has no role in contrast anaphylaxis."
        }
      }
    },
    {
      "externalId": "d5-allergy-hae-laryngeal-attack-on-demand-treatment-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "b65e1c72d480fb4d6a16d22da3bd489050f0d52ed49531fc59744642aa91507d",
        "ranaze_step3_prd": "b65e1c72d480fb4d6a16d22da3bd489050f0d52ed49531fc59744642aa91507d"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A second dose of diphenhydramine as the only disease-directed therapy is inappropriate because repeating antihistamine delays effective bradykinin-directed treatment."
            },
            {
              "id": "B",
              "text": "Option B: Fresh frozen plasma before using any HAE-specific agent is inappropriate because plasma can be used if specific therapy is unavailable but is not preferred before it."
            },
            {
              "id": "C",
              "text": "Option D: High-dose systemic glucocorticoids and observation for six hours is inappropriate because steroids do not rapidly reverse bradykinin-mediated airway edema."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A second dose of diphenhydramine as the only disease-directed therapy is inappropriate because repeating antihistamine delays effective bradykinin-directed treatment."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fresh frozen plasma before using any HAE-specific agent is inappropriate because plasma can be used if specific therapy is unavailable but is not preferred before it."
            },
            {
              "id": "B",
              "text": "Option A: A second dose of diphenhydramine as the only disease-directed therapy is inappropriate because repeating antihistamine delays effective bradykinin-directed treatment."
            },
            {
              "id": "C",
              "text": "Option D: High-dose systemic glucocorticoids and observation for six hours is inappropriate because steroids do not rapidly reverse bradykinin-mediated airway edema."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fresh frozen plasma before using any HAE-specific agent is inappropriate because plasma can be used if specific therapy is unavailable but is not preferred before it."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose systemic glucocorticoids and observation for six hours is inappropriate because steroids do not rapidly reverse bradykinin-mediated airway edema."
            },
            {
              "id": "B",
              "text": "Option A: A second dose of diphenhydramine as the only disease-directed therapy is inappropriate because repeating antihistamine delays effective bradykinin-directed treatment."
            },
            {
              "id": "C",
              "text": "Option B: Fresh frozen plasma before using any HAE-specific agent is inappropriate because plasma can be used if specific therapy is unavailable but is not preferred before it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose systemic glucocorticoids and observation for six hours is inappropriate because steroids do not rapidly reverse bradykinin-mediated airway edema."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcutaneous epinephrine every 20 minutes until swelling resolves is inappropriate because repeated epinephrine is not definitive therapy for C1-inhibitor-deficient HAE."
            },
            {
              "id": "B",
              "text": "Option A: A second dose of diphenhydramine as the only disease-directed therapy is inappropriate because repeating antihistamine delays effective bradykinin-directed treatment."
            },
            {
              "id": "C",
              "text": "Option B: Fresh frozen plasma before using any HAE-specific agent is inappropriate because plasma can be used if specific therapy is unavailable but is not preferred before it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcutaneous epinephrine every 20 minutes until swelling resolves is inappropriate because repeated epinephrine is not definitive therapy for C1-inhibitor-deficient HAE."
        }
      }
    },
    {
      "externalId": "d5-allergy-refractory-anaphylaxis-epinephrine-infusion-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "916cfc934b3c8ec7678c5af08fff36f107bc500aee4f7dee9d932bf42d28e2fc",
        "ranaze_step3_prd": "916cfc934b3c8ec7678c5af08fff36f107bc500aee4f7dee9d932bf42d28e2fc"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous diphenhydramine and wait for the blood pressure to improve is inappropriate because antihistamines do not treat shock or airway obstruction."
            },
            {
              "id": "B",
              "text": "Option C: Give an intravenous epinephrine bolus of 1 mg despite a spontaneous pulse is inappropriate because an arrest-dose bolus is unsafe with spontaneous circulation."
            },
            {
              "id": "C",
              "text": "Option D: Replace epinephrine with intravenous hydrocortisone is inappropriate because steroids act too slowly to rescue refractory shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous diphenhydramine and wait for the blood pressure to improve is inappropriate because antihistamines do not treat shock or airway obstruction."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give an intravenous epinephrine bolus of 1 mg despite a spontaneous pulse is inappropriate because an arrest-dose bolus is unsafe with spontaneous circulation."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous diphenhydramine and wait for the blood pressure to improve is inappropriate because antihistamines do not treat shock or airway obstruction."
            },
            {
              "id": "C",
              "text": "Option D: Replace epinephrine with intravenous hydrocortisone is inappropriate because steroids act too slowly to rescue refractory shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give an intravenous epinephrine bolus of 1 mg despite a spontaneous pulse is inappropriate because an arrest-dose bolus is unsafe with spontaneous circulation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Replace epinephrine with intravenous hydrocortisone is inappropriate because steroids act too slowly to rescue refractory shock."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous diphenhydramine and wait for the blood pressure to improve is inappropriate because antihistamines do not treat shock or airway obstruction."
            },
            {
              "id": "C",
              "text": "Option C: Give an intravenous epinephrine bolus of 1 mg despite a spontaneous pulse is inappropriate because an arrest-dose bolus is unsafe with spontaneous circulation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Replace epinephrine with intravenous hydrocortisone is inappropriate because steroids act too slowly to rescue refractory shock."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin norepinephrine alone and discontinue epinephrine is inappropriate because adjunct vasopressors may be added, but epinephrine remains the core infusion."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous diphenhydramine and wait for the blood pressure to improve is inappropriate because antihistamines do not treat shock or airway obstruction."
            },
            {
              "id": "C",
              "text": "Option C: Give an intravenous epinephrine bolus of 1 mg despite a spontaneous pulse is inappropriate because an arrest-dose bolus is unsafe with spontaneous circulation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin norepinephrine alone and discontinue epinephrine is inappropriate because adjunct vasopressors may be added, but epinephrine remains the core infusion."
        }
      }
    },
    {
      "externalId": "d5-cardiology-electrical-storm-multimodal-treatment-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "a98c80309bc30453128fdc6af4ce5aec87b20506486f7ec2527cf7bb0a8baad4",
        "ranaze_step3_prd": "a98c80309bc30453128fdc6af4ce5aec87b20506486f7ec2527cf7bb0a8baad4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply a magnet and discharge him once shocks stop is inappropriate because magnet application can disable ICD tachytherapy and does not treat ongoing VT substrate; discharge is unsafe."
            },
            {
              "id": "B",
              "text": "Option C: Discontinue beta blockade because it can lower the ventricular rate is inappropriate because beta blockade is a key component of sympathetic suppression when hemodynamically tolerated."
            },
            {
              "id": "C",
              "text": "Option D: Give flecainide despite his prior myocardial infarction and structural heart disease is inappropriate because class IC therapy is contraindicated in prior MI and significant structural heart disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply a magnet and discharge him once shocks stop is inappropriate because magnet application can disable ICD tachytherapy and does not treat ongoing VT substrate; discharge is unsafe."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discontinue beta blockade because it can lower the ventricular rate is inappropriate because beta blockade is a key component of sympathetic suppression when hemodynamically tolerated."
            },
            {
              "id": "B",
              "text": "Option B: Apply a magnet and discharge him once shocks stop is inappropriate because magnet application can disable ICD tachytherapy and does not treat ongoing VT substrate; discharge is unsafe."
            },
            {
              "id": "C",
              "text": "Option D: Give flecainide despite his prior myocardial infarction and structural heart disease is inappropriate because class IC therapy is contraindicated in prior MI and significant structural heart disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discontinue beta blockade because it can lower the ventricular rate is inappropriate because beta blockade is a key component of sympathetic suppression when hemodynamically tolerated."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give flecainide despite his prior myocardial infarction and structural heart disease is inappropriate because class IC therapy is contraindicated in prior MI and significant structural heart disease."
            },
            {
              "id": "B",
              "text": "Option B: Apply a magnet and discharge him once shocks stop is inappropriate because magnet application can disable ICD tachytherapy and does not treat ongoing VT substrate; discharge is unsafe."
            },
            {
              "id": "C",
              "text": "Option C: Discontinue beta blockade because it can lower the ventricular rate is inappropriate because beta blockade is a key component of sympathetic suppression when hemodynamically tolerated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give flecainide despite his prior myocardial infarction and structural heart disease is inappropriate because class IC therapy is contraindicated in prior MI and significant structural heart disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide repeated shocks alone without antiarrhythmic or autonomic therapy is inappropriate because shocks alone increase pain and catecholamine release and do not prevent recurrence."
            },
            {
              "id": "B",
              "text": "Option B: Apply a magnet and discharge him once shocks stop is inappropriate because magnet application can disable ICD tachytherapy and does not treat ongoing VT substrate; discharge is unsafe."
            },
            {
              "id": "C",
              "text": "Option C: Discontinue beta blockade because it can lower the ventricular rate is inappropriate because beta blockade is a key component of sympathetic suppression when hemodynamically tolerated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide repeated shocks alone without antiarrhythmic or autonomic therapy is inappropriate because shocks alone increase pain and catecholamine release and do not prevent recurrence."
        }
      }
    },
    {
      "externalId": "d5-cardiology-obstructive-mechanical-valve-thrombosis-surgery-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "7358044a83595d28374415637d13ce2b2dee42199cb06ddaaae1767ce05b0e29",
        "ranaze_step3_prd": "7358044a83595d28374415637d13ce2b2dee42199cb06ddaaae1767ce05b0e29"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restart oral warfarin alone and repeat echocardiography in 1 month is inappropriate because oral anticoagulation alone cannot promptly restore flow through a critically obstructed valve."
            },
            {
              "id": "B",
              "text": "Option C: Begin apixaban instead of warfarin is inappropriate because dOACs are contraindicated for prevention and treatment of thrombosis in mechanical prosthetic valves."
            },
            {
              "id": "C",
              "text": "Option D: Administer vitamin K to normalize coagulation is inappropriate because vitamin K reverses warfarin and would worsen the thrombotic state."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restart oral warfarin alone and repeat echocardiography in 1 month is inappropriate because oral anticoagulation alone cannot promptly restore flow through a critically obstructed valve."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin apixaban instead of warfarin is inappropriate because dOACs are contraindicated for prevention and treatment of thrombosis in mechanical prosthetic valves."
            },
            {
              "id": "B",
              "text": "Option B: Restart oral warfarin alone and repeat echocardiography in 1 month is inappropriate because oral anticoagulation alone cannot promptly restore flow through a critically obstructed valve."
            },
            {
              "id": "C",
              "text": "Option D: Administer vitamin K to normalize coagulation is inappropriate because vitamin K reverses warfarin and would worsen the thrombotic state."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin apixaban instead of warfarin is inappropriate because dOACs are contraindicated for prevention and treatment of thrombosis in mechanical prosthetic valves."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer vitamin K to normalize coagulation is inappropriate because vitamin K reverses warfarin and would worsen the thrombotic state."
            },
            {
              "id": "B",
              "text": "Option B: Restart oral warfarin alone and repeat echocardiography in 1 month is inappropriate because oral anticoagulation alone cannot promptly restore flow through a critically obstructed valve."
            },
            {
              "id": "C",
              "text": "Option C: Begin apixaban instead of warfarin is inappropriate because dOACs are contraindicated for prevention and treatment of thrombosis in mechanical prosthetic valves."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer vitamin K to normalize coagulation is inappropriate because vitamin K reverses warfarin and would worsen the thrombotic state."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use aspirin monotherapy because the thrombus is mobile is inappropriate because aspirin does not dissolve a large obstructive mechanical-valve thrombus."
            },
            {
              "id": "B",
              "text": "Option B: Restart oral warfarin alone and repeat echocardiography in 1 month is inappropriate because oral anticoagulation alone cannot promptly restore flow through a critically obstructed valve."
            },
            {
              "id": "C",
              "text": "Option C: Begin apixaban instead of warfarin is inappropriate because dOACs are contraindicated for prevention and treatment of thrombosis in mechanical prosthetic valves."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use aspirin monotherapy because the thrombus is mobile is inappropriate because aspirin does not dissolve a large obstructive mechanical-valve thrombus."
        }
      }
    },
    {
      "externalId": "d5-cardiology-post-mi-ventricular-septal-rupture-shock-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "05816ec1e1d9f127b0b0e7b383d608bccbe1e6823d308da76145c83cc89d5527",
        "ranaze_step3_prd": "05816ec1e1d9f127b0b0e7b383d608bccbe1e6823d308da76145c83cc89d5527"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat medically with an ACE inhibitor and defer intervention permanently is inappropriate because afterload reduction can be a bridge only when tolerated; it cannot definitively treat a large structural rupture."
            },
            {
              "id": "B",
              "text": "Option C: Repeat coronary angiography only because recurrent coronary occlusion explains the shunt is inappropriate because recurrent ischemia does not create the demonstrated interventricular communication."
            },
            {
              "id": "C",
              "text": "Option D: Administer fibrinolysis to close the septal defect is inappropriate because thrombolysis neither repairs necrotic septum nor controls the shunt and adds hemorrhagic risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat medically with an ACE inhibitor and defer intervention permanently is inappropriate because afterload reduction can be a bridge only when tolerated; it cannot definitively treat a large structural rupture."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat coronary angiography only because recurrent coronary occlusion explains the shunt is inappropriate because recurrent ischemia does not create the demonstrated interventricular communication."
            },
            {
              "id": "B",
              "text": "Option B: Treat medically with an ACE inhibitor and defer intervention permanently is inappropriate because afterload reduction can be a bridge only when tolerated; it cannot definitively treat a large structural rupture."
            },
            {
              "id": "C",
              "text": "Option D: Administer fibrinolysis to close the septal defect is inappropriate because thrombolysis neither repairs necrotic septum nor controls the shunt and adds hemorrhagic risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat coronary angiography only because recurrent coronary occlusion explains the shunt is inappropriate because recurrent ischemia does not create the demonstrated interventricular communication."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer fibrinolysis to close the septal defect is inappropriate because thrombolysis neither repairs necrotic septum nor controls the shunt and adds hemorrhagic risk."
            },
            {
              "id": "B",
              "text": "Option B: Treat medically with an ACE inhibitor and defer intervention permanently is inappropriate because afterload reduction can be a bridge only when tolerated; it cannot definitively treat a large structural rupture."
            },
            {
              "id": "C",
              "text": "Option C: Repeat coronary angiography only because recurrent coronary occlusion explains the shunt is inappropriate because recurrent ischemia does not create the demonstrated interventricular communication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer fibrinolysis to close the septal defect is inappropriate because thrombolysis neither repairs necrotic septum nor controls the shunt and adds hemorrhagic risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform pericardiocentesis for presumed free-wall rupture is inappropriate because tamponade physiology and pericardial blood are absent; the defect is intracardiac."
            },
            {
              "id": "B",
              "text": "Option B: Treat medically with an ACE inhibitor and defer intervention permanently is inappropriate because afterload reduction can be a bridge only when tolerated; it cannot definitively treat a large structural rupture."
            },
            {
              "id": "C",
              "text": "Option C: Repeat coronary angiography only because recurrent coronary occlusion explains the shunt is inappropriate because recurrent ischemia does not create the demonstrated interventricular communication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform pericardiocentesis for presumed free-wall rupture is inappropriate because tamponade physiology and pericardial blood are absent; the defect is intracardiac."
        }
      }
    },
    {
      "externalId": "d5-dermatology-generalized-pustular-psoriasis-spesolimab-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "062bd5a0db309d489d34a80b8a50a7704ae27aa20c53c8c5327fc60cdd31293e",
        "ranaze_step3_prd": "062bd5a0db309d489d34a80b8a50a7704ae27aa20c53c8c5327fc60cdd31293e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restart a high-dose systemic glucocorticoid followed by abrupt withdrawal is inappropriate because abrupt steroid withdrawal can trigger or worsen GPP."
            },
            {
              "id": "B",
              "text": "Option C: Topical mupirocin alone is inappropriate because topical antibacterial treatment cannot control systemic sterile inflammation."
            },
            {
              "id": "C",
              "text": "Option D: Oral terbinafine is inappropriate because antifungal therapy does not target GPP."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restart a high-dose systemic glucocorticoid followed by abrupt withdrawal is inappropriate because abrupt steroid withdrawal can trigger or worsen GPP."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical mupirocin alone is inappropriate because topical antibacterial treatment cannot control systemic sterile inflammation."
            },
            {
              "id": "B",
              "text": "Option B: Restart a high-dose systemic glucocorticoid followed by abrupt withdrawal is inappropriate because abrupt steroid withdrawal can trigger or worsen GPP."
            },
            {
              "id": "C",
              "text": "Option D: Oral terbinafine is inappropriate because antifungal therapy does not target GPP."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical mupirocin alone is inappropriate because topical antibacterial treatment cannot control systemic sterile inflammation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral terbinafine is inappropriate because antifungal therapy does not target GPP."
            },
            {
              "id": "B",
              "text": "Option B: Restart a high-dose systemic glucocorticoid followed by abrupt withdrawal is inappropriate because abrupt steroid withdrawal can trigger or worsen GPP."
            },
            {
              "id": "C",
              "text": "Option C: Topical mupirocin alone is inappropriate because topical antibacterial treatment cannot control systemic sterile inflammation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral terbinafine is inappropriate because antifungal therapy does not target GPP."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ultraviolet phototherapy during the unstable febrile phase is inappropriate because phototherapy is inappropriate during an acutely unstable pustular eruption."
            },
            {
              "id": "B",
              "text": "Option B: Restart a high-dose systemic glucocorticoid followed by abrupt withdrawal is inappropriate because abrupt steroid withdrawal can trigger or worsen GPP."
            },
            {
              "id": "C",
              "text": "Option C: Topical mupirocin alone is inappropriate because topical antibacterial treatment cannot control systemic sterile inflammation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ultraviolet phototherapy during the unstable febrile phase is inappropriate because phototherapy is inappropriate during an acutely unstable pustular eruption."
        }
      }
    },
    {
      "externalId": "d5-dermatology-postoperative-pyoderma-avoid-debridement-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "9e38773bfa996b737f6376687b9f3f3ced95a670763257f034e55ffc49355266",
        "ranaze_step3_prd": "9e38773bfa996b737f6376687b9f3f3ced95a670763257f034e55ffc49355266"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform wider emergent debridement for presumed necrotizing infection is inappropriate because more trauma can dramatically enlarge PG lesions."
            },
            {
              "id": "B",
              "text": "Option C: Continue antibiotics alone for 6 weeks is inappropriate because antibiotics do not treat sterile neutrophilic disease."
            },
            {
              "id": "C",
              "text": "Option D: Apply topical antifungal therapy is inappropriate because fungal infection is unsupported by repeated cultures and histology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform wider emergent debridement for presumed necrotizing infection is inappropriate because more trauma can dramatically enlarge PG lesions."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue antibiotics alone for 6 weeks is inappropriate because antibiotics do not treat sterile neutrophilic disease."
            },
            {
              "id": "B",
              "text": "Option A: Perform wider emergent debridement for presumed necrotizing infection is inappropriate because more trauma can dramatically enlarge PG lesions."
            },
            {
              "id": "C",
              "text": "Option D: Apply topical antifungal therapy is inappropriate because fungal infection is unsupported by repeated cultures and histology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue antibiotics alone for 6 weeks is inappropriate because antibiotics do not treat sterile neutrophilic disease."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply topical antifungal therapy is inappropriate because fungal infection is unsupported by repeated cultures and histology."
            },
            {
              "id": "B",
              "text": "Option A: Perform wider emergent debridement for presumed necrotizing infection is inappropriate because more trauma can dramatically enlarge PG lesions."
            },
            {
              "id": "C",
              "text": "Option C: Continue antibiotics alone for 6 weeks is inappropriate because antibiotics do not treat sterile neutrophilic disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply topical antifungal therapy is inappropriate because fungal infection is unsupported by repeated cultures and histology."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Close the wounds primarily under tension is inappropriate because tension and surgical trauma can worsen active disease."
            },
            {
              "id": "B",
              "text": "Option A: Perform wider emergent debridement for presumed necrotizing infection is inappropriate because more trauma can dramatically enlarge PG lesions."
            },
            {
              "id": "C",
              "text": "Option C: Continue antibiotics alone for 6 weeks is inappropriate because antibiotics do not treat sterile neutrophilic disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Close the wounds primarily under tension is inappropriate because tension and surgical trauma can worsen active disease."
        }
      }
    },
    {
      "externalId": "d5-dermatology-severe-pemphigus-rituximab-steroids-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "affd124064f1ea8c161c2223f4484a1da26bcc13e33b6adee2d4b2b53cec5a49",
        "ranaze_step3_prd": "affd124064f1ea8c161c2223f4484a1da26bcc13e33b6adee2d4b2b53cec5a49"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-potency topical corticosteroid alone is inappropriate because topical treatment alone cannot control extensive mucocutaneous disease."
            },
            {
              "id": "B",
              "text": "Option C: Dapsone monotherapy is inappropriate because dapsone is not adequate monotherapy for severe PV."
            },
            {
              "id": "C",
              "text": "Option D: Surgical debridement of all erosions is inappropriate because debridement injures fragile skin without treating autoantibodies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-potency topical corticosteroid alone is inappropriate because topical treatment alone cannot control extensive mucocutaneous disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dapsone monotherapy is inappropriate because dapsone is not adequate monotherapy for severe PV."
            },
            {
              "id": "B",
              "text": "Option A: High-potency topical corticosteroid alone is inappropriate because topical treatment alone cannot control extensive mucocutaneous disease."
            },
            {
              "id": "C",
              "text": "Option D: Surgical debridement of all erosions is inappropriate because debridement injures fragile skin without treating autoantibodies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dapsone monotherapy is inappropriate because dapsone is not adequate monotherapy for severe PV."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Surgical debridement of all erosions is inappropriate because debridement injures fragile skin without treating autoantibodies."
            },
            {
              "id": "B",
              "text": "Option A: High-potency topical corticosteroid alone is inappropriate because topical treatment alone cannot control extensive mucocutaneous disease."
            },
            {
              "id": "C",
              "text": "Option C: Dapsone monotherapy is inappropriate because dapsone is not adequate monotherapy for severe PV."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Surgical debridement of all erosions is inappropriate because debridement injures fragile skin without treating autoantibodies."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Broad-spectrum antibiotics until every blister resolves is inappropriate because antibiotics treat secondary infection, not autoimmune blister formation."
            },
            {
              "id": "B",
              "text": "Option A: High-potency topical corticosteroid alone is inappropriate because topical treatment alone cannot control extensive mucocutaneous disease."
            },
            {
              "id": "C",
              "text": "Option C: Dapsone monotherapy is inappropriate because dapsone is not adequate monotherapy for severe PV."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Broad-spectrum antibiotics until every blister resolves is inappropriate because antibiotics treat secondary infection, not autoimmune blister formation."
        }
      }
    },
    {
      "externalId": "d5-endocrine-hhs-controlled-osmolality-correction-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "8cad57c638ad94826ce8f9f7527ed3267fb7b3b718486b63c4a52deb3088a6a7",
        "ranaze_step3_prd": "8cad57c638ad94826ce8f9f7527ed3267fb7b3b718486b63c4a52deb3088a6a7"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give a large insulin bolus before further fluid because glucose must normalize within 2 hours is inappropriate because an insulin bolus before adequate volume replacement can abruptly lower osmolality and worsen circulatory collapse."
            },
            {
              "id": "B",
              "text": "Option C: Infuse hypotonic free water rapidly until measured sodium is below 135 mEq/L is inappropriate because rapid free-water delivery risks cerebral edema and unsafe sodium correction."
            },
            {
              "id": "C",
              "text": "Option D: Withhold all fluid because heart failure is an absolute contraindication is inappropriate because heart failure mandates smaller, reassessed boluses, not untreated severe hypovolemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give a large insulin bolus before further fluid because glucose must normalize within 2 hours is inappropriate because an insulin bolus before adequate volume replacement can abruptly lower osmolality and worsen circulatory collapse."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Infuse hypotonic free water rapidly until measured sodium is below 135 mEq/L is inappropriate because rapid free-water delivery risks cerebral edema and unsafe sodium correction."
            },
            {
              "id": "B",
              "text": "Option B: Give a large insulin bolus before further fluid because glucose must normalize within 2 hours is inappropriate because an insulin bolus before adequate volume replacement can abruptly lower osmolality and worsen circulatory collapse."
            },
            {
              "id": "C",
              "text": "Option D: Withhold all fluid because heart failure is an absolute contraindication is inappropriate because heart failure mandates smaller, reassessed boluses, not untreated severe hypovolemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Infuse hypotonic free water rapidly until measured sodium is below 135 mEq/L is inappropriate because rapid free-water delivery risks cerebral edema and unsafe sodium correction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold all fluid because heart failure is an absolute contraindication is inappropriate because heart failure mandates smaller, reassessed boluses, not untreated severe hypovolemia."
            },
            {
              "id": "B",
              "text": "Option B: Give a large insulin bolus before further fluid because glucose must normalize within 2 hours is inappropriate because an insulin bolus before adequate volume replacement can abruptly lower osmolality and worsen circulatory collapse."
            },
            {
              "id": "C",
              "text": "Option C: Infuse hypotonic free water rapidly until measured sodium is below 135 mEq/L is inappropriate because rapid free-water delivery risks cerebral edema and unsafe sodium correction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold all fluid because heart failure is an absolute contraindication is inappropriate because heart failure mandates smaller, reassessed boluses, not untreated severe hypovolemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer bicarbonate because every hyperglycemic crisis is acidemic is inappropriate because normal pH and bicarbonate show no indication for bicarbonate."
            },
            {
              "id": "B",
              "text": "Option B: Give a large insulin bolus before further fluid because glucose must normalize within 2 hours is inappropriate because an insulin bolus before adequate volume replacement can abruptly lower osmolality and worsen circulatory collapse."
            },
            {
              "id": "C",
              "text": "Option C: Infuse hypotonic free water rapidly until measured sodium is below 135 mEq/L is inappropriate because rapid free-water delivery risks cerebral edema and unsafe sodium correction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer bicarbonate because every hyperglycemic crisis is acidemic is inappropriate because normal pH and bicarbonate show no indication for bicarbonate."
        }
      }
    },
    {
      "externalId": "d5-endocrine-pheochromocytoma-multisystem-crisis-alpha-first-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "2577771b167371f2d38273f97c8b070f50462f8907e54e896f52b2fab13d336f",
        "ranaze_step3_prd": "2577771b167371f2d38273f97c8b070f50462f8907e54e896f52b2fab13d336f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase propranolol immediately as the sole vasoactive treatment is inappropriate because pure beta blockade can worsen vasoconstriction and afterload through unopposed alpha-receptor stimulation."
            },
            {
              "id": "B",
              "text": "Option C: Proceed directly to adrenalectomy before hemodynamic stabilization is inappropriate because unprepared emergency adrenalectomy exposes the patient to massive catecholamine release and greater mortality."
            },
            {
              "id": "C",
              "text": "Option D: Give epinephrine for every hypotensive interval without addressing catecholamine excess is inappropriate because indiscriminate catecholamine administration can amplify the crisis; shock management must be individualized with expert hemodynamic support."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase propranolol immediately as the sole vasoactive treatment is inappropriate because pure beta blockade can worsen vasoconstriction and afterload through unopposed alpha-receptor stimulation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly to adrenalectomy before hemodynamic stabilization is inappropriate because unprepared emergency adrenalectomy exposes the patient to massive catecholamine release and greater mortality."
            },
            {
              "id": "B",
              "text": "Option B: Increase propranolol immediately as the sole vasoactive treatment is inappropriate because pure beta blockade can worsen vasoconstriction and afterload through unopposed alpha-receptor stimulation."
            },
            {
              "id": "C",
              "text": "Option D: Give epinephrine for every hypotensive interval without addressing catecholamine excess is inappropriate because indiscriminate catecholamine administration can amplify the crisis; shock management must be individualized with expert hemodynamic support."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly to adrenalectomy before hemodynamic stabilization is inappropriate because unprepared emergency adrenalectomy exposes the patient to massive catecholamine release and greater mortality."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give epinephrine for every hypotensive interval without addressing catecholamine excess is inappropriate because indiscriminate catecholamine administration can amplify the crisis; shock management must be individualized with expert hemodynamic support."
            },
            {
              "id": "B",
              "text": "Option B: Increase propranolol immediately as the sole vasoactive treatment is inappropriate because pure beta blockade can worsen vasoconstriction and afterload through unopposed alpha-receptor stimulation."
            },
            {
              "id": "C",
              "text": "Option C: Proceed directly to adrenalectomy before hemodynamic stabilization is inappropriate because unprepared emergency adrenalectomy exposes the patient to massive catecholamine release and greater mortality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give epinephrine for every hypotensive interval without addressing catecholamine excess is inappropriate because indiscriminate catecholamine administration can amplify the crisis; shock management must be individualized with expert hemodynamic support."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with thrombolysis for presumed coronary occlusion is inappropriate because the global reversible pattern and catecholamine syndrome do not establish an occlusive coronary thrombus."
            },
            {
              "id": "B",
              "text": "Option B: Increase propranolol immediately as the sole vasoactive treatment is inappropriate because pure beta blockade can worsen vasoconstriction and afterload through unopposed alpha-receptor stimulation."
            },
            {
              "id": "C",
              "text": "Option C: Proceed directly to adrenalectomy before hemodynamic stabilization is inappropriate because unprepared emergency adrenalectomy exposes the patient to massive catecholamine release and greater mortality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with thrombolysis for presumed coronary occlusion is inappropriate because the global reversible pattern and catecholamine syndrome do not establish an occlusive coronary thrombus."
        }
      }
    },
    {
      "externalId": "d5-endocrine-sulfonylurea-recurrent-hypoglycemia-octreotide-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "344348716144de3f7a2cab767c4e832ad3a9f33cb36d1ed7c7a77553628f43ff",
        "ranaze_step3_prd": "344348716144de3f7a2cab767c4e832ad3a9f33cb36d1ed7c7a77553628f43ff"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue escalating dextrose alone and discharge after one normal glucose value is inappropriate because dextrose monotherapy can perpetuate insulin secretion, and a single normal value does not exclude relapse."
            },
            {
              "id": "B",
              "text": "Option C: Administer glucagon continuously as definitive therapy despite depleted hepatic glycogen is inappropriate because glucagon may be ineffective after glycogen depletion and can stimulate further insulin release."
            },
            {
              "id": "C",
              "text": "Option D: Give exogenous insulin to suppress endogenous insulin secretion is inappropriate because exogenous insulin would worsen hypoglycemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue escalating dextrose alone and discharge after one normal glucose value is inappropriate because dextrose monotherapy can perpetuate insulin secretion, and a single normal value does not exclude relapse."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer glucagon continuously as definitive therapy despite depleted hepatic glycogen is inappropriate because glucagon may be ineffective after glycogen depletion and can stimulate further insulin release."
            },
            {
              "id": "B",
              "text": "Option B: Continue escalating dextrose alone and discharge after one normal glucose value is inappropriate because dextrose monotherapy can perpetuate insulin secretion, and a single normal value does not exclude relapse."
            },
            {
              "id": "C",
              "text": "Option D: Give exogenous insulin to suppress endogenous insulin secretion is inappropriate because exogenous insulin would worsen hypoglycemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer glucagon continuously as definitive therapy despite depleted hepatic glycogen is inappropriate because glucagon may be ineffective after glycogen depletion and can stimulate further insulin release."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give exogenous insulin to suppress endogenous insulin secretion is inappropriate because exogenous insulin would worsen hypoglycemia."
            },
            {
              "id": "B",
              "text": "Option B: Continue escalating dextrose alone and discharge after one normal glucose value is inappropriate because dextrose monotherapy can perpetuate insulin secretion, and a single normal value does not exclude relapse."
            },
            {
              "id": "C",
              "text": "Option C: Administer glucagon continuously as definitive therapy despite depleted hepatic glycogen is inappropriate because glucagon may be ineffective after glycogen depletion and can stimulate further insulin release."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give exogenous insulin to suppress endogenous insulin secretion is inappropriate because exogenous insulin would worsen hypoglycemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start hemodialysis as the standard antidote for all sulfonylureas is inappropriate because supportive therapy and octreotide are standard; dialysis is not routine definitive sulfonylurea removal."
            },
            {
              "id": "B",
              "text": "Option B: Continue escalating dextrose alone and discharge after one normal glucose value is inappropriate because dextrose monotherapy can perpetuate insulin secretion, and a single normal value does not exclude relapse."
            },
            {
              "id": "C",
              "text": "Option C: Administer glucagon continuously as definitive therapy despite depleted hepatic glycogen is inappropriate because glucagon may be ineffective after glycogen depletion and can stimulate further insulin release."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start hemodialysis as the standard antidote for all sulfonylureas is inappropriate because supportive therapy and octreotide are standard; dialysis is not routine definitive sulfonylurea removal."
        }
      }
    },
    {
      "externalId": "d5-environmental-exertional-heat-stroke-cool-first-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "e48334cad7330c7541a9a604a4767dc0db77ba0d9127185838d37609dc857673",
        "ranaze_step3_prd": "e48334cad7330c7541a9a604a4767dc0db77ba0d9127185838d37609dc857673"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transport immediately without on-site cooling so laboratory studies can be obtained first is inappropriate because a 12-minute untreated transport prolongs damaging hyperthermia when definitive field cooling is immediately available."
            },
            {
              "id": "B",
              "text": "Option C: Give acetaminophen and apply ice packs only to the neck, axillae, and groin is inappropriate because antipyretics are ineffective in heat stroke, and limited ice-pack application cools much more slowly than immersion."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous dantrolene before initiating external cooling is inappropriate because dantrolene is not first-line therapy for exertional heat stroke and must not delay rapid external cooling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transport immediately without on-site cooling so laboratory studies can be obtained first is inappropriate because a 12-minute untreated transport prolongs damaging hyperthermia when definitive field cooling is immediately available."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give acetaminophen and apply ice packs only to the neck, axillae, and groin is inappropriate because antipyretics are ineffective in heat stroke, and limited ice-pack application cools much more slowly than immersion."
            },
            {
              "id": "B",
              "text": "Option B: Transport immediately without on-site cooling so laboratory studies can be obtained first is inappropriate because a 12-minute untreated transport prolongs damaging hyperthermia when definitive field cooling is immediately available."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous dantrolene before initiating external cooling is inappropriate because dantrolene is not first-line therapy for exertional heat stroke and must not delay rapid external cooling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give acetaminophen and apply ice packs only to the neck, axillae, and groin is inappropriate because antipyretics are ineffective in heat stroke, and limited ice-pack application cools much more slowly than immersion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous dantrolene before initiating external cooling is inappropriate because dantrolene is not first-line therapy for exertional heat stroke and must not delay rapid external cooling."
            },
            {
              "id": "B",
              "text": "Option B: Transport immediately without on-site cooling so laboratory studies can be obtained first is inappropriate because a 12-minute untreated transport prolongs damaging hyperthermia when definitive field cooling is immediately available."
            },
            {
              "id": "C",
              "text": "Option C: Give acetaminophen and apply ice packs only to the neck, axillae, and groin is inappropriate because antipyretics are ineffective in heat stroke, and limited ice-pack application cools much more slowly than immersion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous dantrolene before initiating external cooling is inappropriate because dantrolene is not first-line therapy for exertional heat stroke and must not delay rapid external cooling."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cover him with wet towels and wait for the temperature to fall spontaneously before activating emergency services is inappropriate because passive waiting is unsafe; emergency services and active whole-body cooling should occur immediately."
            },
            {
              "id": "B",
              "text": "Option B: Transport immediately without on-site cooling so laboratory studies can be obtained first is inappropriate because a 12-minute untreated transport prolongs damaging hyperthermia when definitive field cooling is immediately available."
            },
            {
              "id": "C",
              "text": "Option C: Give acetaminophen and apply ice packs only to the neck, axillae, and groin is inappropriate because antipyretics are ineffective in heat stroke, and limited ice-pack application cools much more slowly than immersion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cover him with wet towels and wait for the temperature to fall spontaneously before activating emergency services is inappropriate because passive waiting is unsafe; emergency services and active whole-body cooling should occur immediately."
        }
      }
    },
    {
      "externalId": "d5-environmental-neurologic-decompression-sickness-recompression-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "f1df1bb9f153694ccc5611eb252e7cce7b42e43f24823921827e6233ace1bc4a",
        "ranaze_step3_prd": "f1df1bb9f153694ccc5611eb252e7cce7b42e43f24823921827e6233ace1bc4a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discontinue oxygen and discharge him because the neurologic symptoms improved is inappropriate because symptoms may recur after oxygen is stopped, and neurologic decompression illness requires specialist evaluation and usually recompression."
            },
            {
              "id": "B",
              "text": "Option C: Return him to depth in the water for recompression by his dive partner is inappropriate because in-water recompression is hazardous and is not the preferred option when medical evacuation is available."
            },
            {
              "id": "C",
              "text": "Option D: Arrange rapid transport in an unpressurized aircraft at the highest safe altitude is inappropriate because lower cabin pressure can expand inert-gas bubbles; transport should avoid altitude when possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discontinue oxygen and discharge him because the neurologic symptoms improved is inappropriate because symptoms may recur after oxygen is stopped, and neurologic decompression illness requires specialist evaluation and usually recompression."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Return him to depth in the water for recompression by his dive partner is inappropriate because in-water recompression is hazardous and is not the preferred option when medical evacuation is available."
            },
            {
              "id": "B",
              "text": "Option A: Discontinue oxygen and discharge him because the neurologic symptoms improved is inappropriate because symptoms may recur after oxygen is stopped, and neurologic decompression illness requires specialist evaluation and usually recompression."
            },
            {
              "id": "C",
              "text": "Option D: Arrange rapid transport in an unpressurized aircraft at the highest safe altitude is inappropriate because lower cabin pressure can expand inert-gas bubbles; transport should avoid altitude when possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Return him to depth in the water for recompression by his dive partner is inappropriate because in-water recompression is hazardous and is not the preferred option when medical evacuation is available."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange rapid transport in an unpressurized aircraft at the highest safe altitude is inappropriate because lower cabin pressure can expand inert-gas bubbles; transport should avoid altitude when possible."
            },
            {
              "id": "B",
              "text": "Option A: Discontinue oxygen and discharge him because the neurologic symptoms improved is inappropriate because symptoms may recur after oxygen is stopped, and neurologic decompression illness requires specialist evaluation and usually recompression."
            },
            {
              "id": "C",
              "text": "Option C: Return him to depth in the water for recompression by his dive partner is inappropriate because in-water recompression is hazardous and is not the preferred option when medical evacuation is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange rapid transport in an unpressurized aircraft at the highest safe altitude is inappropriate because lower cabin pressure can expand inert-gas bubbles; transport should avoid altitude when possible."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a prophylactic anticoagulant and observe without hyperbaric consultation is inappropriate because anticoagulation does not eliminate inert-gas bubbles and is not a substitute for oxygen and recompression."
            },
            {
              "id": "B",
              "text": "Option A: Discontinue oxygen and discharge him because the neurologic symptoms improved is inappropriate because symptoms may recur after oxygen is stopped, and neurologic decompression illness requires specialist evaluation and usually recompression."
            },
            {
              "id": "C",
              "text": "Option C: Return him to depth in the water for recompression by his dive partner is inappropriate because in-water recompression is hazardous and is not the preferred option when medical evacuation is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a prophylactic anticoagulant and observe without hyperbaric consultation is inappropriate because anticoagulation does not eliminate inert-gas bubbles and is not a substitute for oxygen and recompression."
        }
      }
    },
    {
      "externalId": "d5-environmental-severe-frostbite-iloprost-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "92683117a5dc1aea146f8851b623bedbec0891110b581e356c87076ef58f6332",
        "ranaze_step3_prd": "92683117a5dc1aea146f8851b623bedbec0891110b581e356c87076ef58f6332"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate surgical amputation at the visible margin of cyanosis is inappropriate because the ultimate tissue boundary is not evident immediately after rewarming; premature amputation can sacrifice viable tissue."
            },
            {
              "id": "B",
              "text": "Option B: Systemic unfractionated heparin as sole therapy is inappropriate because heparin monotherapy has insufficient evidence and does not provide the recommended vasodilator limb-salvage strategy."
            },
            {
              "id": "C",
              "text": "Option D: Intra-arterial tissue plasminogen activator despite the recent intracranial hemorrhage is inappropriate because recent intracranial hemorrhage creates unacceptable bleeding risk from thrombolysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate surgical amputation at the visible margin of cyanosis is inappropriate because the ultimate tissue boundary is not evident immediately after rewarming; premature amputation can sacrifice viable tissue."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Systemic unfractionated heparin as sole therapy is inappropriate because heparin monotherapy has insufficient evidence and does not provide the recommended vasodilator limb-salvage strategy."
            },
            {
              "id": "B",
              "text": "Option A: Immediate surgical amputation at the visible margin of cyanosis is inappropriate because the ultimate tissue boundary is not evident immediately after rewarming; premature amputation can sacrifice viable tissue."
            },
            {
              "id": "C",
              "text": "Option D: Intra-arterial tissue plasminogen activator despite the recent intracranial hemorrhage is inappropriate because recent intracranial hemorrhage creates unacceptable bleeding risk from thrombolysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Systemic unfractionated heparin as sole therapy is inappropriate because heparin monotherapy has insufficient evidence and does not provide the recommended vasodilator limb-salvage strategy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intra-arterial tissue plasminogen activator despite the recent intracranial hemorrhage is inappropriate because recent intracranial hemorrhage creates unacceptable bleeding risk from thrombolysis."
            },
            {
              "id": "B",
              "text": "Option A: Immediate surgical amputation at the visible margin of cyanosis is inappropriate because the ultimate tissue boundary is not evident immediately after rewarming; premature amputation can sacrifice viable tissue."
            },
            {
              "id": "C",
              "text": "Option B: Systemic unfractionated heparin as sole therapy is inappropriate because heparin monotherapy has insufficient evidence and does not provide the recommended vasodilator limb-salvage strategy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intra-arterial tissue plasminogen activator despite the recent intracranial hemorrhage is inappropriate because recent intracranial hemorrhage creates unacceptable bleeding risk from thrombolysis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hyperbaric oxygen as established first-line monotherapy is inappropriate because evidence is insufficient to make hyperbaric oxygen established first-line monotherapy for frostbite."
            },
            {
              "id": "B",
              "text": "Option A: Immediate surgical amputation at the visible margin of cyanosis is inappropriate because the ultimate tissue boundary is not evident immediately after rewarming; premature amputation can sacrifice viable tissue."
            },
            {
              "id": "C",
              "text": "Option B: Systemic unfractionated heparin as sole therapy is inappropriate because heparin monotherapy has insufficient evidence and does not provide the recommended vasodilator limb-salvage strategy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hyperbaric oxygen as established first-line monotherapy is inappropriate because evidence is insufficient to make hyperbaric oxygen established first-line monotherapy for frostbite."
        }
      }
    },
    {
      "externalId": "d5-expansion-ent-lemierre-source-control-antibiotics-001",
      "expectedHashes": {
        "ranaze_step3_uat": "ab804729f5a312d73a5e1ea1d1adfb2484f41b9f4df25b6202fac02c40510f35",
        "ranaze_step3_prd": "ab804729f5a312d73a5e1ea1d1adfb2484f41b9f4df25b6202fac02c40510f35"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give therapeutic anticoagulation alone because the primary process is venous thromboembolism is inappropriate because anticoagulation alone does not treat bacteremia or abscess and is not universally required."
            },
            {
              "id": "B",
              "text": "Option C: Excise the internal jugular vein immediately in every case is inappropriate because jugular excision is an exceptional rescue measure, not routine first-line management."
            },
            {
              "id": "C",
              "text": "Option D: Treat with azithromycin for 5 days without source control is inappropriate because a short macrolide course is inadequate for septic thrombophlebitis and metastatic abscesses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give therapeutic anticoagulation alone because the primary process is venous thromboembolism is inappropriate because anticoagulation alone does not treat bacteremia or abscess and is not universally required."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Excise the internal jugular vein immediately in every case is inappropriate because jugular excision is an exceptional rescue measure, not routine first-line management."
            },
            {
              "id": "B",
              "text": "Option B: Give therapeutic anticoagulation alone because the primary process is venous thromboembolism is inappropriate because anticoagulation alone does not treat bacteremia or abscess and is not universally required."
            },
            {
              "id": "C",
              "text": "Option D: Treat with azithromycin for 5 days without source control is inappropriate because a short macrolide course is inadequate for septic thrombophlebitis and metastatic abscesses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Excise the internal jugular vein immediately in every case is inappropriate because jugular excision is an exceptional rescue measure, not routine first-line management."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with azithromycin for 5 days without source control is inappropriate because a short macrolide course is inadequate for septic thrombophlebitis and metastatic abscesses."
            },
            {
              "id": "B",
              "text": "Option B: Give therapeutic anticoagulation alone because the primary process is venous thromboembolism is inappropriate because anticoagulation alone does not treat bacteremia or abscess and is not universally required."
            },
            {
              "id": "C",
              "text": "Option C: Excise the internal jugular vein immediately in every case is inappropriate because jugular excision is an exceptional rescue measure, not routine first-line management."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with azithromycin for 5 days without source control is inappropriate because a short macrolide course is inadequate for septic thrombophlebitis and metastatic abscesses."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold antibiotics because septic pulmonary emboli indicate that the infection has already disseminated is inappropriate because dissemination increases, rather than removes, the need for urgent antimicrobial and source-control therapy."
            },
            {
              "id": "B",
              "text": "Option B: Give therapeutic anticoagulation alone because the primary process is venous thromboembolism is inappropriate because anticoagulation alone does not treat bacteremia or abscess and is not universally required."
            },
            {
              "id": "C",
              "text": "Option C: Excise the internal jugular vein immediately in every case is inappropriate because jugular excision is an exceptional rescue measure, not routine first-line management."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold antibiotics because septic pulmonary emboli indicate that the infection has already disseminated is inappropriate because dissemination increases, rather than removes, the need for urgent antimicrobial and source-control therapy."
        }
      }
    },
    {
      "externalId": "d5-expansion-ent-rhino-orbital-mucor-combined-treatment-001",
      "expectedHashes": {
        "ranaze_step3_uat": "faae45a2735522a369893c088b66913a4a03129ab81ea1b79bb16a34b9ddd861",
        "ranaze_step3_prd": "faae45a2735522a369893c088b66913a4a03129ab81ea1b79bb16a34b9ddd861"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start voriconazole alone and defer surgery until fungal culture identifies the species is inappropriate because voriconazole is not reliably active against Mucorales, and culture delay permits rapid angioinvasion."
            },
            {
              "id": "B",
              "text": "Option C: Begin fluconazole and corticosteroids to reduce orbital inflammation is inappropriate because fluconazole is inactive and corticosteroids worsen an uncontrolled invasive fungal infection."
            },
            {
              "id": "C",
              "text": "Option D: Correct the ketoacidosis first and repeat MRI in 48 hours before starting antifungal therapy is inappropriate because metabolic correction is essential but cannot precede or delay antifungal therapy and debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start voriconazole alone and defer surgery until fungal culture identifies the species is inappropriate because voriconazole is not reliably active against Mucorales, and culture delay permits rapid angioinvasion."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin fluconazole and corticosteroids to reduce orbital inflammation is inappropriate because fluconazole is inactive and corticosteroids worsen an uncontrolled invasive fungal infection."
            },
            {
              "id": "B",
              "text": "Option B: Start voriconazole alone and defer surgery until fungal culture identifies the species is inappropriate because voriconazole is not reliably active against Mucorales, and culture delay permits rapid angioinvasion."
            },
            {
              "id": "C",
              "text": "Option D: Correct the ketoacidosis first and repeat MRI in 48 hours before starting antifungal therapy is inappropriate because metabolic correction is essential but cannot precede or delay antifungal therapy and debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin fluconazole and corticosteroids to reduce orbital inflammation is inappropriate because fluconazole is inactive and corticosteroids worsen an uncontrolled invasive fungal infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Correct the ketoacidosis first and repeat MRI in 48 hours before starting antifungal therapy is inappropriate because metabolic correction is essential but cannot precede or delay antifungal therapy and debridement."
            },
            {
              "id": "B",
              "text": "Option B: Start voriconazole alone and defer surgery until fungal culture identifies the species is inappropriate because voriconazole is not reliably active against Mucorales, and culture delay permits rapid angioinvasion."
            },
            {
              "id": "C",
              "text": "Option C: Begin fluconazole and corticosteroids to reduce orbital inflammation is inappropriate because fluconazole is inactive and corticosteroids worsen an uncontrolled invasive fungal infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Correct the ketoacidosis first and repeat MRI in 48 hours before starting antifungal therapy is inappropriate because metabolic correction is essential but cannot precede or delay antifungal therapy and debridement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform orbital radiation therapy followed by oral itraconazole is inappropriate because radiation has no role, and itraconazole is not recommended primary therapy for this fulminant infection."
            },
            {
              "id": "B",
              "text": "Option B: Start voriconazole alone and defer surgery until fungal culture identifies the species is inappropriate because voriconazole is not reliably active against Mucorales, and culture delay permits rapid angioinvasion."
            },
            {
              "id": "C",
              "text": "Option C: Begin fluconazole and corticosteroids to reduce orbital inflammation is inappropriate because fluconazole is inactive and corticosteroids worsen an uncontrolled invasive fungal infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform orbital radiation therapy followed by oral itraconazole is inappropriate because radiation has no role, and itraconazole is not recommended primary therapy for this fulminant infection."
        }
      }
    },
    {
      "externalId": "d5-expansion-ent-ssnhl-intratympanic-salvage-001",
      "expectedHashes": {
        "ranaze_step3_uat": "0612df9023501f462c8cdbd21b098f006b0741c595dc146562ad5c550556563c",
        "ranaze_step3_prd": "0612df9023501f462c8cdbd21b098f006b0741c595dc146562ad5c550556563c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat the same systemic prednisone course for another 6 weeks is inappropriate because prolonged repeat systemic steroid therapy is not supported as salvage and increases adverse effects."
            },
            {
              "id": "B",
              "text": "Option C: Prescribe acyclovir because most idiopathic cases are proven viral infections is inappropriate because routine antiviral therapy is specifically discouraged because a viral cause is rarely established and benefit is unproven."
            },
            {
              "id": "C",
              "text": "Option D: Order routine head CT before considering further treatment is inappropriate because mRI has already addressed retrocochlear pathology; routine head CT is not recommended."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat the same systemic prednisone course for another 6 weeks is inappropriate because prolonged repeat systemic steroid therapy is not supported as salvage and increases adverse effects."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe acyclovir because most idiopathic cases are proven viral infections is inappropriate because routine antiviral therapy is specifically discouraged because a viral cause is rarely established and benefit is unproven."
            },
            {
              "id": "B",
              "text": "Option B: Repeat the same systemic prednisone course for another 6 weeks is inappropriate because prolonged repeat systemic steroid therapy is not supported as salvage and increases adverse effects."
            },
            {
              "id": "C",
              "text": "Option D: Order routine head CT before considering further treatment is inappropriate because mRI has already addressed retrocochlear pathology; routine head CT is not recommended."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe acyclovir because most idiopathic cases are proven viral infections is inappropriate because routine antiviral therapy is specifically discouraged because a viral cause is rarely established and benefit is unproven."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order routine head CT before considering further treatment is inappropriate because mRI has already addressed retrocochlear pathology; routine head CT is not recommended."
            },
            {
              "id": "B",
              "text": "Option B: Repeat the same systemic prednisone course for another 6 weeks is inappropriate because prolonged repeat systemic steroid therapy is not supported as salvage and increases adverse effects."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe acyclovir because most idiopathic cases are proven viral infections is inappropriate because routine antiviral therapy is specifically discouraged because a viral cause is rarely established and benefit is unproven."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order routine head CT before considering further treatment is inappropriate because mRI has already addressed retrocochlear pathology; routine head CT is not recommended."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer all salvage treatment until 6 months after symptom onset is inappropriate because waiting 6 months would miss the 2\u20136-week intratympanic salvage window."
            },
            {
              "id": "B",
              "text": "Option B: Repeat the same systemic prednisone course for another 6 weeks is inappropriate because prolonged repeat systemic steroid therapy is not supported as salvage and increases adverse effects."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe acyclovir because most idiopathic cases are proven viral infections is inappropriate because routine antiviral therapy is specifically discouraged because a viral cause is rarely established and benefit is unproven."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer all salvage treatment until 6 months after symptom onset is inappropriate because waiting 6 months would miss the 2\u20136-week intratympanic salvage window."
        }
      }
    },
    {
      "externalId": "d5-expansion-environmental-cerebral-arterial-gas-embolism-hbo-001",
      "expectedHashes": {
        "ranaze_step3_uat": "a6ef52abb25e8e353964a614b897f5e6be62e9b6e5df778e5e6578e24b59c82c",
        "ranaze_step3_prd": "a6ef52abb25e8e353964a614b897f5e6be62e9b6e5df778e5e6578e24b59c82c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold oxygen because his pulse oximetry is normal and observe for spontaneous gas absorption is inappropriate because normal SpO2 does not address focal arterial obstruction and does not remove the indication for oxygen."
            },
            {
              "id": "B",
              "text": "Option C: Administer intravenous alteplase using the standard thrombotic-stroke protocol is inappropriate because this is a mechanical gas obstruction with hemorrhagic risk from the procedure; thrombolysis is not standard treatment."
            },
            {
              "id": "C",
              "text": "Option D: Place him upright to prevent gas from reaching the cerebral circulation is inappropriate because upright positioning may promote cephalad migration; standard supine/recovery positioning is preferred."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold oxygen because his pulse oximetry is normal and observe for spontaneous gas absorption is inappropriate because normal SpO2 does not address focal arterial obstruction and does not remove the indication for oxygen."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous alteplase using the standard thrombotic-stroke protocol is inappropriate because this is a mechanical gas obstruction with hemorrhagic risk from the procedure; thrombolysis is not standard treatment."
            },
            {
              "id": "B",
              "text": "Option B: Withhold oxygen because his pulse oximetry is normal and observe for spontaneous gas absorption is inappropriate because normal SpO2 does not address focal arterial obstruction and does not remove the indication for oxygen."
            },
            {
              "id": "C",
              "text": "Option D: Place him upright to prevent gas from reaching the cerebral circulation is inappropriate because upright positioning may promote cephalad migration; standard supine/recovery positioning is preferred."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous alteplase using the standard thrombotic-stroke protocol is inappropriate because this is a mechanical gas obstruction with hemorrhagic risk from the procedure; thrombolysis is not standard treatment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place him upright to prevent gas from reaching the cerebral circulation is inappropriate because upright positioning may promote cephalad migration; standard supine/recovery positioning is preferred."
            },
            {
              "id": "B",
              "text": "Option B: Withhold oxygen because his pulse oximetry is normal and observe for spontaneous gas absorption is inappropriate because normal SpO2 does not address focal arterial obstruction and does not remove the indication for oxygen."
            },
            {
              "id": "C",
              "text": "Option C: Administer intravenous alteplase using the standard thrombotic-stroke protocol is inappropriate because this is a mechanical gas obstruction with hemorrhagic risk from the procedure; thrombolysis is not standard treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place him upright to prevent gas from reaching the cerebral circulation is inappropriate because upright positioning may promote cephalad migration; standard supine/recovery positioning is preferred."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay hyperbaric referral until repeat CT proves persistent gas at 24 hours is inappropriate because visible gas may disappear while secondary injury evolves; clinical suspicion drives urgent treatment."
            },
            {
              "id": "B",
              "text": "Option B: Withhold oxygen because his pulse oximetry is normal and observe for spontaneous gas absorption is inappropriate because normal SpO2 does not address focal arterial obstruction and does not remove the indication for oxygen."
            },
            {
              "id": "C",
              "text": "Option C: Administer intravenous alteplase using the standard thrombotic-stroke protocol is inappropriate because this is a mechanical gas obstruction with hemorrhagic risk from the procedure; thrombolysis is not standard treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay hyperbaric referral until repeat CT proves persistent gas at 24 hours is inappropriate because visible gas may disappear while secondary injury evolves; clinical suspicion drives urgent treatment."
        }
      }
    },
    {
      "externalId": "d5-expansion-environmental-hypothermic-arrest-ecls-rewarming-001",
      "expectedHashes": {
        "ranaze_step3_uat": "a3f65afcdcc3bc315f166c4304012563c25f2e5be57534aecaf12ae1a8c5a0bc",
        "ranaze_step3_prd": "a3f65afcdcc3bc315f166c4304012563c25f2e5be57534aecaf12ae1a8c5a0bc"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Terminate resuscitation because the core temperature is below 28\u00B0C is inappropriate because a low temperature supports, rather than precludes, aggressive rewarming when viability factors are favorable."
            },
            {
              "id": "B",
              "text": "Option C: Warm the extremities rapidly with hot-water immersion as the sole rewarming method is inappropriate because peripheral heat alone risks afterdrop and cannot provide circulation."
            },
            {
              "id": "C",
              "text": "Option D: Wait for spontaneous circulation before beginning active internal rewarming is inappropriate because eCLS rewarming is used precisely because spontaneous circulation is absent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Terminate resuscitation because the core temperature is below 28\u00B0C is inappropriate because a low temperature supports, rather than precludes, aggressive rewarming when viability factors are favorable."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Warm the extremities rapidly with hot-water immersion as the sole rewarming method is inappropriate because peripheral heat alone risks afterdrop and cannot provide circulation."
            },
            {
              "id": "B",
              "text": "Option B: Terminate resuscitation because the core temperature is below 28\u00B0C is inappropriate because a low temperature supports, rather than precludes, aggressive rewarming when viability factors are favorable."
            },
            {
              "id": "C",
              "text": "Option D: Wait for spontaneous circulation before beginning active internal rewarming is inappropriate because eCLS rewarming is used precisely because spontaneous circulation is absent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Warm the extremities rapidly with hot-water immersion as the sole rewarming method is inappropriate because peripheral heat alone risks afterdrop and cannot provide circulation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for spontaneous circulation before beginning active internal rewarming is inappropriate because eCLS rewarming is used precisely because spontaneous circulation is absent."
            },
            {
              "id": "B",
              "text": "Option B: Terminate resuscitation because the core temperature is below 28\u00B0C is inappropriate because a low temperature supports, rather than precludes, aggressive rewarming when viability factors are favorable."
            },
            {
              "id": "C",
              "text": "Option C: Warm the extremities rapidly with hot-water immersion as the sole rewarming method is inappropriate because peripheral heat alone risks afterdrop and cannot provide circulation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for spontaneous circulation before beginning active internal rewarming is inappropriate because eCLS rewarming is used precisely because spontaneous circulation is absent."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use the serum potassium value alone to determine futility is inappropriate because modern guidance favors validated multivariable scores over a single potassium cutoff."
            },
            {
              "id": "B",
              "text": "Option B: Terminate resuscitation because the core temperature is below 28\u00B0C is inappropriate because a low temperature supports, rather than precludes, aggressive rewarming when viability factors are favorable."
            },
            {
              "id": "C",
              "text": "Option C: Warm the extremities rapidly with hot-water immersion as the sole rewarming method is inappropriate because peripheral heat alone risks afterdrop and cannot provide circulation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use the serum potassium value alone to determine futility is inappropriate because modern guidance favors validated multivariable scores over a single potassium cutoff."
        }
      }
    },
    {
      "externalId": "d5-expansion-environmental-lightning-reverse-triage-001",
      "expectedHashes": {
        "ranaze_step3_uat": "3458e1264a45ccf727f85da0f70af776fad1cccdf57ae364fcdb2924465f3814",
        "ranaze_step3_prd": "3458e1264a45ccf727f85da0f70af776fad1cccdf57ae364fcdb2924465f3814"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patient 2 is inappropriate because hemorrhage control is urgent, but it is already controllable and the patient has circulation."
            },
            {
              "id": "B",
              "text": "Option C: Patient 3 is inappropriate because altered mental status requires evaluation, yet spontaneous breathing and pulse make Patient 1 the priority."
            },
            {
              "id": "C",
              "text": "Option D: Patient 4 is inappropriate because a walking patient with superficial burns is lower acuity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patient 2 is inappropriate because hemorrhage control is urgent, but it is already controllable and the patient has circulation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patient 3 is inappropriate because altered mental status requires evaluation, yet spontaneous breathing and pulse make Patient 1 the priority."
            },
            {
              "id": "B",
              "text": "Option B: Patient 2 is inappropriate because hemorrhage control is urgent, but it is already controllable and the patient has circulation."
            },
            {
              "id": "C",
              "text": "Option D: Patient 4 is inappropriate because a walking patient with superficial burns is lower acuity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patient 3 is inappropriate because altered mental status requires evaluation, yet spontaneous breathing and pulse make Patient 1 the priority."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patient 4 is inappropriate because a walking patient with superficial burns is lower acuity."
            },
            {
              "id": "B",
              "text": "Option B: Patient 2 is inappropriate because hemorrhage control is urgent, but it is already controllable and the patient has circulation."
            },
            {
              "id": "C",
              "text": "Option C: Patient 3 is inappropriate because altered mental status requires evaluation, yet spontaneous breathing and pulse make Patient 1 the priority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patient 4 is inappropriate because a walking patient with superficial burns is lower acuity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patient 5 is inappropriate because transient keraunoparalysis can mimic vascular injury but often resolves; pulses are present."
            },
            {
              "id": "B",
              "text": "Option B: Patient 2 is inappropriate because hemorrhage control is urgent, but it is already controllable and the patient has circulation."
            },
            {
              "id": "C",
              "text": "Option C: Patient 3 is inappropriate because altered mental status requires evaluation, yet spontaneous breathing and pulse make Patient 1 the priority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patient 5 is inappropriate because transient keraunoparalysis can mimic vascular injury but often resolves; pulses are present."
        }
      }
    },
    {
      "externalId": "d5-expansion-ethics-family-nondisclosure-request-001",
      "expectedHashes": {
        "ranaze_step3_uat": "ff3c12eea3d7589aa1f6c4cdd035392f8d72418150974491f85c3543ce3a3dd0",
        "ranaze_step3_prd": "ff3c12eea3d7589aa1f6c4cdd035392f8d72418150974491f85c3543ce3a3dd0"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Promise the son that the diagnosis will be permanently concealed is inappropriate because a family member cannot authorize permanent deception of a capable patient."
            },
            {
              "id": "B",
              "text": "Option C: Disclose the diagnosis abruptly in front of the family to demonstrate respect for autonomy is inappropriate because truthful communication should be sensitive and preference-based, not abrupt or performative."
            },
            {
              "id": "C",
              "text": "Option D: Tell only the son because family-centered cultures transfer decisional authority automatically is inappropriate because culture informs the conversation but does not automatically transfer authority away from the patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Promise the son that the diagnosis will be permanently concealed is inappropriate because a family member cannot authorize permanent deception of a capable patient."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Disclose the diagnosis abruptly in front of the family to demonstrate respect for autonomy is inappropriate because truthful communication should be sensitive and preference-based, not abrupt or performative."
            },
            {
              "id": "B",
              "text": "Option B: Promise the son that the diagnosis will be permanently concealed is inappropriate because a family member cannot authorize permanent deception of a capable patient."
            },
            {
              "id": "C",
              "text": "Option D: Tell only the son because family-centered cultures transfer decisional authority automatically is inappropriate because culture informs the conversation but does not automatically transfer authority away from the patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Disclose the diagnosis abruptly in front of the family to demonstrate respect for autonomy is inappropriate because truthful communication should be sensitive and preference-based, not abrupt or performative."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tell only the son because family-centered cultures transfer decisional authority automatically is inappropriate because culture informs the conversation but does not automatically transfer authority away from the patient."
            },
            {
              "id": "B",
              "text": "Option B: Promise the son that the diagnosis will be permanently concealed is inappropriate because a family member cannot authorize permanent deception of a capable patient."
            },
            {
              "id": "C",
              "text": "Option C: Disclose the diagnosis abruptly in front of the family to demonstrate respect for autonomy is inappropriate because truthful communication should be sensitive and preference-based, not abrupt or performative."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tell only the son because family-centered cultures transfer decisional authority automatically is inappropriate because culture informs the conversation but does not automatically transfer authority away from the patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the son to translate the pathology report and decide how much to reveal is inappropriate because a professional interpreter\u2014not a conflicted relative\u2014should support the patient\u0027s private preference assessment."
            },
            {
              "id": "B",
              "text": "Option B: Promise the son that the diagnosis will be permanently concealed is inappropriate because a family member cannot authorize permanent deception of a capable patient."
            },
            {
              "id": "C",
              "text": "Option C: Disclose the diagnosis abruptly in front of the family to demonstrate respect for autonomy is inappropriate because truthful communication should be sensitive and preference-based, not abrupt or performative."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the son to translate the pathology report and decide how much to reveal is inappropriate because a professional interpreter\u2014not a conflicted relative\u2014should support the patient\u0027s private preference assessment."
        }
      }
    },
    {
      "externalId": "d5-expansion-ethics-potentially-inappropriate-icu-treatment-001",
      "expectedHashes": {
        "ranaze_step3_uat": "2cacb9108139931fee35182e2ecf23a88aa3c7d48b5ca77eb45e052336586789",
        "ranaze_step3_prd": "2cacb9108139931fee35182e2ecf23a88aa3c7d48b5ca77eb45e052336586789"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Have the attending unilaterally refuse all current life support immediately is inappropriate because the dispute concerns ECMO, not immediate withdrawal of all support, and unilateral action bypasses available due process."
            },
            {
              "id": "B",
              "text": "Option C: Initiate ECMO because a surrogate may demand any treatment with a physiologic effect is inappropriate because surrogates represent patient values but cannot compel every technically possible intervention."
            },
            {
              "id": "C",
              "text": "Option D: Ask a court to decide before using any hospital conflict-resolution process is inappropriate because institutional mediation, second opinion, committee review, transfer, and appeal usually precede litigation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Have the attending unilaterally refuse all current life support immediately is inappropriate because the dispute concerns ECMO, not immediate withdrawal of all support, and unilateral action bypasses available due process."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Initiate ECMO because a surrogate may demand any treatment with a physiologic effect is inappropriate because surrogates represent patient values but cannot compel every technically possible intervention."
            },
            {
              "id": "B",
              "text": "Option B: Have the attending unilaterally refuse all current life support immediately is inappropriate because the dispute concerns ECMO, not immediate withdrawal of all support, and unilateral action bypasses available due process."
            },
            {
              "id": "C",
              "text": "Option D: Ask a court to decide before using any hospital conflict-resolution process is inappropriate because institutional mediation, second opinion, committee review, transfer, and appeal usually precede litigation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Initiate ECMO because a surrogate may demand any treatment with a physiologic effect is inappropriate because surrogates represent patient values but cannot compel every technically possible intervention."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask a court to decide before using any hospital conflict-resolution process is inappropriate because institutional mediation, second opinion, committee review, transfer, and appeal usually precede litigation."
            },
            {
              "id": "B",
              "text": "Option B: Have the attending unilaterally refuse all current life support immediately is inappropriate because the dispute concerns ECMO, not immediate withdrawal of all support, and unilateral action bypasses available due process."
            },
            {
              "id": "C",
              "text": "Option C: Initiate ECMO because a surrogate may demand any treatment with a physiologic effect is inappropriate because surrogates represent patient values but cannot compel every technically possible intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask a court to decide before using any hospital conflict-resolution process is inappropriate because institutional mediation, second opinion, committee review, transfer, and appeal usually precede litigation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Label ECMO strictly futile and omit further discussion because it can transiently improve oxygenation is inappropriate because because ECMO could oxygenate, the request is not strictly physiologically futile."
            },
            {
              "id": "B",
              "text": "Option B: Have the attending unilaterally refuse all current life support immediately is inappropriate because the dispute concerns ECMO, not immediate withdrawal of all support, and unilateral action bypasses available due process."
            },
            {
              "id": "C",
              "text": "Option C: Initiate ECMO because a surrogate may demand any treatment with a physiologic effect is inappropriate because surrogates represent patient values but cannot compel every technically possible intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Label ECMO strictly futile and omit further discussion because it can transiently improve oxygenation is inappropriate because because ECMO could oxygenate, the request is not strictly physiologically futile."
        }
      }
    },
    {
      "externalId": "d5-expansion-ethics-unrepresented-patient-process-001",
      "expectedHashes": {
        "ranaze_step3_uat": "bd2657e271425f079a27dc7093e8fd1b6c275950af5aa5de6e8138b6aebd12de",
        "ranaze_step3_prd": "bd2657e271425f079a27dc7093e8fd1b6c275950af5aa5de6e8138b6aebd12de"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Have the attending physician authorize both procedures alone because the patient has no surrogate is inappropriate because unilateral attending decisions lack safeguards against bias and conflict in this vulnerable population."
            },
            {
              "id": "B",
              "text": "Option C: Ask the longest-serving bedside nurse to act as the legal surrogate is inappropriate because bedside knowledge is valuable, but employment duration does not confer surrogate authority."
            },
            {
              "id": "C",
              "text": "Option D: Wait until cardiac arrest recurs so emergency implied consent governs all subsequent care is inappropriate because deliberately waiting for an emergency evades rather than respects fair decision-making."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Have the attending physician authorize both procedures alone because the patient has no surrogate is inappropriate because unilateral attending decisions lack safeguards against bias and conflict in this vulnerable population."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the longest-serving bedside nurse to act as the legal surrogate is inappropriate because bedside knowledge is valuable, but employment duration does not confer surrogate authority."
            },
            {
              "id": "B",
              "text": "Option B: Have the attending physician authorize both procedures alone because the patient has no surrogate is inappropriate because unilateral attending decisions lack safeguards against bias and conflict in this vulnerable population."
            },
            {
              "id": "C",
              "text": "Option D: Wait until cardiac arrest recurs so emergency implied consent governs all subsequent care is inappropriate because deliberately waiting for an emergency evades rather than respects fair decision-making."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the longest-serving bedside nurse to act as the legal surrogate is inappropriate because bedside knowledge is valuable, but employment duration does not confer surrogate authority."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait until cardiac arrest recurs so emergency implied consent governs all subsequent care is inappropriate because deliberately waiting for an emergency evades rather than respects fair decision-making."
            },
            {
              "id": "B",
              "text": "Option B: Have the attending physician authorize both procedures alone because the patient has no surrogate is inappropriate because unilateral attending decisions lack safeguards against bias and conflict in this vulnerable population."
            },
            {
              "id": "C",
              "text": "Option C: Ask the longest-serving bedside nurse to act as the legal surrogate is inappropriate because bedside knowledge is valuable, but employment duration does not confer surrogate authority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait until cardiac arrest recurs so emergency implied consent governs all subsequent care is inappropriate because deliberately waiting for an emergency evades rather than respects fair decision-making."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Automatically withhold life-sustaining treatment because no one can consent is inappropriate because absence of a surrogate neither authorizes automatic treatment nor automatic withdrawal."
            },
            {
              "id": "B",
              "text": "Option B: Have the attending physician authorize both procedures alone because the patient has no surrogate is inappropriate because unilateral attending decisions lack safeguards against bias and conflict in this vulnerable population."
            },
            {
              "id": "C",
              "text": "Option C: Ask the longest-serving bedside nurse to act as the legal surrogate is inappropriate because bedside knowledge is valuable, but employment duration does not confer surrogate authority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Automatically withhold life-sustaining treatment because no one can consent is inappropriate because absence of a surrogate neither authorizes automatic treatment nor automatic withdrawal."
        }
      }
    },
    {
      "externalId": "d5-expansion-geriatrics-benzodiazepine-omission-withdrawal-001",
      "expectedHashes": {
        "ranaze_step3_uat": "d14361826027ef9b4c10cd1d6ed51e25cf1b6a2fc70eedb606e2bf04a11e72d6",
        "ranaze_step3_prd": "d14361826027ef9b4c10cd1d6ed51e25cf1b6a2fc70eedb606e2bf04a11e72d6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue withholding lorazepam and use haloperidol alone for the hallucinations is inappropriate because antipsychotic monotherapy does not restore GABA activity or prevent withdrawal seizures."
            },
            {
              "id": "B",
              "text": "Option C: Administer flumazenil to reverse residual benzodiazepine effect is inappropriate because flumazenil antagonizes benzodiazepines and can precipitate seizures in a dependent patient."
            },
            {
              "id": "C",
              "text": "Option D: Discharge immediately because withdrawal is self-limited and medically benign is inappropriate because complicated benzodiazepine withdrawal is not benign and requires monitored treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue withholding lorazepam and use haloperidol alone for the hallucinations is inappropriate because antipsychotic monotherapy does not restore GABA activity or prevent withdrawal seizures."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer flumazenil to reverse residual benzodiazepine effect is inappropriate because flumazenil antagonizes benzodiazepines and can precipitate seizures in a dependent patient."
            },
            {
              "id": "B",
              "text": "Option B: Continue withholding lorazepam and use haloperidol alone for the hallucinations is inappropriate because antipsychotic monotherapy does not restore GABA activity or prevent withdrawal seizures."
            },
            {
              "id": "C",
              "text": "Option D: Discharge immediately because withdrawal is self-limited and medically benign is inappropriate because complicated benzodiazepine withdrawal is not benign and requires monitored treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer flumazenil to reverse residual benzodiazepine effect is inappropriate because flumazenil antagonizes benzodiazepines and can precipitate seizures in a dependent patient."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge immediately because withdrawal is self-limited and medically benign is inappropriate because complicated benzodiazepine withdrawal is not benign and requires monitored treatment."
            },
            {
              "id": "B",
              "text": "Option B: Continue withholding lorazepam and use haloperidol alone for the hallucinations is inappropriate because antipsychotic monotherapy does not restore GABA activity or prevent withdrawal seizures."
            },
            {
              "id": "C",
              "text": "Option C: Administer flumazenil to reverse residual benzodiazepine effect is inappropriate because flumazenil antagonizes benzodiazepines and can precipitate seizures in a dependent patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge immediately because withdrawal is self-limited and medically benign is inappropriate because complicated benzodiazepine withdrawal is not benign and requires monitored treatment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin a rapid 3-day taper after one rescue dose regardless of symptom response is inappropriate because a fixed rapid taper after 9 years of use risks recurrent delirium and seizures."
            },
            {
              "id": "B",
              "text": "Option B: Continue withholding lorazepam and use haloperidol alone for the hallucinations is inappropriate because antipsychotic monotherapy does not restore GABA activity or prevent withdrawal seizures."
            },
            {
              "id": "C",
              "text": "Option C: Administer flumazenil to reverse residual benzodiazepine effect is inappropriate because flumazenil antagonizes benzodiazepines and can precipitate seizures in a dependent patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin a rapid 3-day taper after one rescue dose regardless of symptom response is inappropriate because a fixed rapid taper after 9 years of use risks recurrent delirium and seizures."
        }
      }
    },
    {
      "externalId": "d5-expansion-geriatrics-dlb-hallucination-management-001",
      "expectedHashes": {
        "ranaze_step3_uat": "57698bdb4d41c288863a02597ea1a475a3c5d99659d6dd9696501099bb1523f1",
        "ranaze_step3_prd": "57698bdb4d41c288863a02597ea1a475a3c5d99659d6dd9696501099bb1523f1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin scheduled haloperidol because it has the least effect on cognition is inappropriate because haloperidol is among the agents most likely to provoke a severe sensitivity reaction in DLB."
            },
            {
              "id": "B",
              "text": "Option C: Begin high-dose carbidopa-levodopa specifically to eliminate hallucinations is inappropriate because levodopa may improve disabling motor symptoms but can aggravate psychosis and is not a hallucination treatment."
            },
            {
              "id": "C",
              "text": "Option D: Begin benztropine to treat parkinsonism and hallucinations simultaneously is inappropriate because anticholinergic therapy worsens cognition and hallucinations in older adults with dementia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin scheduled haloperidol because it has the least effect on cognition is inappropriate because haloperidol is among the agents most likely to provoke a severe sensitivity reaction in DLB."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin high-dose carbidopa-levodopa specifically to eliminate hallucinations is inappropriate because levodopa may improve disabling motor symptoms but can aggravate psychosis and is not a hallucination treatment."
            },
            {
              "id": "B",
              "text": "Option B: Begin scheduled haloperidol because it has the least effect on cognition is inappropriate because haloperidol is among the agents most likely to provoke a severe sensitivity reaction in DLB."
            },
            {
              "id": "C",
              "text": "Option D: Begin benztropine to treat parkinsonism and hallucinations simultaneously is inappropriate because anticholinergic therapy worsens cognition and hallucinations in older adults with dementia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin high-dose carbidopa-levodopa specifically to eliminate hallucinations is inappropriate because levodopa may improve disabling motor symptoms but can aggravate psychosis and is not a hallucination treatment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin benztropine to treat parkinsonism and hallucinations simultaneously is inappropriate because anticholinergic therapy worsens cognition and hallucinations in older adults with dementia."
            },
            {
              "id": "B",
              "text": "Option B: Begin scheduled haloperidol because it has the least effect on cognition is inappropriate because haloperidol is among the agents most likely to provoke a severe sensitivity reaction in DLB."
            },
            {
              "id": "C",
              "text": "Option C: Begin high-dose carbidopa-levodopa specifically to eliminate hallucinations is inappropriate because levodopa may improve disabling motor symptoms but can aggravate psychosis and is not a hallucination treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin benztropine to treat parkinsonism and hallucinations simultaneously is inappropriate because anticholinergic therapy worsens cognition and hallucinations in older adults with dementia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin long-term lorazepam monotherapy for daytime hallucinations is inappropriate because benzodiazepines increase sedation, falls, and confusion and are not routine daytime antipsychotic therapy."
            },
            {
              "id": "B",
              "text": "Option B: Begin scheduled haloperidol because it has the least effect on cognition is inappropriate because haloperidol is among the agents most likely to provoke a severe sensitivity reaction in DLB."
            },
            {
              "id": "C",
              "text": "Option C: Begin high-dose carbidopa-levodopa specifically to eliminate hallucinations is inappropriate because levodopa may improve disabling motor symptoms but can aggravate psychosis and is not a hallucination treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin long-term lorazepam monotherapy for daytime hallucinations is inappropriate because benzodiazepines increase sedation, falls, and confusion and are not routine daytime antipsychotic therapy."
        }
      }
    },
    {
      "externalId": "d5-expansion-geriatrics-noh-supine-hypertension-001",
      "expectedHashes": {
        "ranaze_step3_uat": "e89489bb5b0ce643fc64191c1fff8ebc8731342cdd8c11f98941a56196dbc624",
        "ranaze_step3_prd": "e89489bb5b0ce643fc64191c1fff8ebc8731342cdd8c11f98941a56196dbc624"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start fludrocortisone at bedtime and sleep completely flat is inappropriate because fludrocortisone expands volume and can aggravate supine hypertension; flat sleep also worsens it."
            },
            {
              "id": "B",
              "text": "Option C: Treat to a normal supine pressure with a long-acting antihypertensive each morning is inappropriate because long-acting antihypertensive effect during the day can intensify standing hypotension and falls."
            },
            {
              "id": "C",
              "text": "Option D: Restrict salt and fluid throughout the day and prescribe a loop diuretic is inappropriate because volume restriction and diuresis worsen orthostatic perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start fludrocortisone at bedtime and sleep completely flat is inappropriate because fludrocortisone expands volume and can aggravate supine hypertension; flat sleep also worsens it."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat to a normal supine pressure with a long-acting antihypertensive each morning is inappropriate because long-acting antihypertensive effect during the day can intensify standing hypotension and falls."
            },
            {
              "id": "B",
              "text": "Option B: Start fludrocortisone at bedtime and sleep completely flat is inappropriate because fludrocortisone expands volume and can aggravate supine hypertension; flat sleep also worsens it."
            },
            {
              "id": "C",
              "text": "Option D: Restrict salt and fluid throughout the day and prescribe a loop diuretic is inappropriate because volume restriction and diuresis worsen orthostatic perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat to a normal supine pressure with a long-acting antihypertensive each morning is inappropriate because long-acting antihypertensive effect during the day can intensify standing hypotension and falls."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restrict salt and fluid throughout the day and prescribe a loop diuretic is inappropriate because volume restriction and diuresis worsen orthostatic perfusion."
            },
            {
              "id": "B",
              "text": "Option B: Start fludrocortisone at bedtime and sleep completely flat is inappropriate because fludrocortisone expands volume and can aggravate supine hypertension; flat sleep also worsens it."
            },
            {
              "id": "C",
              "text": "Option C: Treat to a normal supine pressure with a long-acting antihypertensive each morning is inappropriate because long-acting antihypertensive effect during the day can intensify standing hypotension and falls."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restrict salt and fluid throughout the day and prescribe a loop diuretic is inappropriate because volume restriction and diuresis worsen orthostatic perfusion."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold all orthostatic treatment because any supine hypertension makes pressors absolutely contraindicated is inappropriate because supine hypertension complicates but does not absolutely prohibit treatment of disabling neurogenic orthostasis."
            },
            {
              "id": "B",
              "text": "Option B: Start fludrocortisone at bedtime and sleep completely flat is inappropriate because fludrocortisone expands volume and can aggravate supine hypertension; flat sleep also worsens it."
            },
            {
              "id": "C",
              "text": "Option C: Treat to a normal supine pressure with a long-acting antihypertensive each morning is inappropriate because long-acting antihypertensive effect during the day can intensify standing hypotension and falls."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold all orthostatic treatment because any supine hypertension makes pressors absolutely contraindicated is inappropriate because supine hypertension complicates but does not absolutely prohibit treatment of disabling neurogenic orthostasis."
        }
      }
    },
    {
      "externalId": "d5-expansion-gynecology-heterotopic-rupture-salpingectomy-001",
      "expectedHashes": {
        "ranaze_step3_uat": "05a7ff7ce288449004c00ca138084f66e0f96741a48588f8862621e652a94fb7",
        "ranaze_step3_prd": "05a7ff7ce288449004c00ca138084f66e0f96741a48588f8862621e652a94fb7"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Systemic methotrexate followed by serial beta-hCG measurements is inappropriate because systemic methotrexate would injure the viable IUP and is too slow for rupture."
            },
            {
              "id": "B",
              "text": "Option C: Dilation and curettage of the uterus to stop the intra-abdominal bleeding is inappropriate because uterine evacuation sacrifices the desired IUP and cannot control tubal hemorrhage."
            },
            {
              "id": "C",
              "text": "Option D: Expectant management because a viable intrauterine pregnancy excludes ectopic rupture is inappropriate because the coexistence of an IUP and ectopic gestation defines heterotopic pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Systemic methotrexate followed by serial beta-hCG measurements is inappropriate because systemic methotrexate would injure the viable IUP and is too slow for rupture."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dilation and curettage of the uterus to stop the intra-abdominal bleeding is inappropriate because uterine evacuation sacrifices the desired IUP and cannot control tubal hemorrhage."
            },
            {
              "id": "B",
              "text": "Option B: Systemic methotrexate followed by serial beta-hCG measurements is inappropriate because systemic methotrexate would injure the viable IUP and is too slow for rupture."
            },
            {
              "id": "C",
              "text": "Option D: Expectant management because a viable intrauterine pregnancy excludes ectopic rupture is inappropriate because the coexistence of an IUP and ectopic gestation defines heterotopic pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dilation and curettage of the uterus to stop the intra-abdominal bleeding is inappropriate because uterine evacuation sacrifices the desired IUP and cannot control tubal hemorrhage."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Expectant management because a viable intrauterine pregnancy excludes ectopic rupture is inappropriate because the coexistence of an IUP and ectopic gestation defines heterotopic pregnancy."
            },
            {
              "id": "B",
              "text": "Option B: Systemic methotrexate followed by serial beta-hCG measurements is inappropriate because systemic methotrexate would injure the viable IUP and is too slow for rupture."
            },
            {
              "id": "C",
              "text": "Option C: Dilation and curettage of the uterus to stop the intra-abdominal bleeding is inappropriate because uterine evacuation sacrifices the desired IUP and cannot control tubal hemorrhage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Expectant management because a viable intrauterine pregnancy excludes ectopic rupture is inappropriate because the coexistence of an IUP and ectopic gestation defines heterotopic pregnancy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ultrasound-guided potassium chloride injection only despite hemodynamic shock and hemoperitoneum is inappropriate because local injection does not provide immediate source control in shock from rupture."
            },
            {
              "id": "B",
              "text": "Option B: Systemic methotrexate followed by serial beta-hCG measurements is inappropriate because systemic methotrexate would injure the viable IUP and is too slow for rupture."
            },
            {
              "id": "C",
              "text": "Option C: Dilation and curettage of the uterus to stop the intra-abdominal bleeding is inappropriate because uterine evacuation sacrifices the desired IUP and cannot control tubal hemorrhage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ultrasound-guided potassium chloride injection only despite hemodynamic shock and hemoperitoneum is inappropriate because local injection does not provide immediate source control in shock from rupture."
        }
      }
    },
    {
      "externalId": "d5-expansion-gynecology-postpartum-ovarian-vein-thrombosis-001",
      "expectedHashes": {
        "ranaze_step3_uat": "4937615a3a5952debdcbd696acedcd26c33010983830f2554b91d69066ff6509",
        "ranaze_step3_prd": "4937615a3a5952debdcbd696acedcd26c33010983830f2554b91d69066ff6509"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate ovarian-vein excision as routine first-line treatment is inappropriate because modern management is medical; vein excision is not routine."
            },
            {
              "id": "B",
              "text": "Option C: Stop antibiotics and use aspirin alone for 6 weeks is inappropriate because aspirin is not therapeutic anticoagulation for acute OVT, and infection remains untreated."
            },
            {
              "id": "C",
              "text": "Option D: Provide prophylactic-dose anticoagulation only because the thrombosis is postpartum is inappropriate because a confirmed symptomatic clot requires treatment dose, not prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate ovarian-vein excision as routine first-line treatment is inappropriate because modern management is medical; vein excision is not routine."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop antibiotics and use aspirin alone for 6 weeks is inappropriate because aspirin is not therapeutic anticoagulation for acute OVT, and infection remains untreated."
            },
            {
              "id": "B",
              "text": "Option B: Perform immediate ovarian-vein excision as routine first-line treatment is inappropriate because modern management is medical; vein excision is not routine."
            },
            {
              "id": "C",
              "text": "Option D: Provide prophylactic-dose anticoagulation only because the thrombosis is postpartum is inappropriate because a confirmed symptomatic clot requires treatment dose, not prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop antibiotics and use aspirin alone for 6 weeks is inappropriate because aspirin is not therapeutic anticoagulation for acute OVT, and infection remains untreated."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide prophylactic-dose anticoagulation only because the thrombosis is postpartum is inappropriate because a confirmed symptomatic clot requires treatment dose, not prophylaxis."
            },
            {
              "id": "B",
              "text": "Option B: Perform immediate ovarian-vein excision as routine first-line treatment is inappropriate because modern management is medical; vein excision is not routine."
            },
            {
              "id": "C",
              "text": "Option C: Stop antibiotics and use aspirin alone for 6 weeks is inappropriate because aspirin is not therapeutic anticoagulation for acute OVT, and infection remains untreated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide prophylactic-dose anticoagulation only because the thrombosis is postpartum is inappropriate because a confirmed symptomatic clot requires treatment dose, not prophylaxis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe without treatment because postpartum ovarian-vein thrombosis is always benign is inappropriate because symptomatic OVT can extend or embolize and is not a benign incidental finding."
            },
            {
              "id": "B",
              "text": "Option B: Perform immediate ovarian-vein excision as routine first-line treatment is inappropriate because modern management is medical; vein excision is not routine."
            },
            {
              "id": "C",
              "text": "Option C: Stop antibiotics and use aspirin alone for 6 weeks is inappropriate because aspirin is not therapeutic anticoagulation for acute OVT, and infection remains untreated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe without treatment because postpartum ovarian-vein thrombosis is always benign is inappropriate because symptomatic OVT can extend or embolize and is not a benign incidental finding."
        }
      }
    },
    {
      "externalId": "d5-expansion-gynecology-toa-failed-antibiotics-drainage-001",
      "expectedHashes": {
        "ranaze_step3_uat": "cbb3a3e5456b00a624fbf04c6aebe9544137c886d103408afeb67996809f9941",
        "ranaze_step3_prd": "cbb3a3e5456b00a624fbf04c6aebe9544137c886d103408afeb67996809f9941"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue the unchanged antibiotic regimen alone for another 2 weeks before considering source control is inappropriate because an unchanged large abscess after 72 hours predicts failure and ongoing sepsis risk."
            },
            {
              "id": "B",
              "text": "Option C: Perform immediate total hysterectomy and bilateral salpingo-oophorectomy is inappropriate because radical surgery is unnecessary before less invasive drainage in this stable premenopausal patient."
            },
            {
              "id": "C",
              "text": "Option D: Discharge with oral doxycycline monotherapy is inappropriate because doxycycline alone lacks adequate anaerobic and broad PID coverage and discharge is unsafe."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue the unchanged antibiotic regimen alone for another 2 weeks before considering source control is inappropriate because an unchanged large abscess after 72 hours predicts failure and ongoing sepsis risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate total hysterectomy and bilateral salpingo-oophorectomy is inappropriate because radical surgery is unnecessary before less invasive drainage in this stable premenopausal patient."
            },
            {
              "id": "B",
              "text": "Option B: Continue the unchanged antibiotic regimen alone for another 2 weeks before considering source control is inappropriate because an unchanged large abscess after 72 hours predicts failure and ongoing sepsis risk."
            },
            {
              "id": "C",
              "text": "Option D: Discharge with oral doxycycline monotherapy is inappropriate because doxycycline alone lacks adequate anaerobic and broad PID coverage and discharge is unsafe."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate total hysterectomy and bilateral salpingo-oophorectomy is inappropriate because radical surgery is unnecessary before less invasive drainage in this stable premenopausal patient."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with oral doxycycline monotherapy is inappropriate because doxycycline alone lacks adequate anaerobic and broad PID coverage and discharge is unsafe."
            },
            {
              "id": "B",
              "text": "Option B: Continue the unchanged antibiotic regimen alone for another 2 weeks before considering source control is inappropriate because an unchanged large abscess after 72 hours predicts failure and ongoing sepsis risk."
            },
            {
              "id": "C",
              "text": "Option C: Perform immediate total hysterectomy and bilateral salpingo-oophorectomy is inappropriate because radical surgery is unnecessary before less invasive drainage in this stable premenopausal patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with oral doxycycline monotherapy is inappropriate because doxycycline alone lacks adequate anaerobic and broad PID coverage and discharge is unsafe."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop antibiotics and aspirate the abscess only if it ruptures is inappropriate because waiting for rupture risks peritonitis, septic shock, and emergent radical surgery."
            },
            {
              "id": "B",
              "text": "Option B: Continue the unchanged antibiotic regimen alone for another 2 weeks before considering source control is inappropriate because an unchanged large abscess after 72 hours predicts failure and ongoing sepsis risk."
            },
            {
              "id": "C",
              "text": "Option C: Perform immediate total hysterectomy and bilateral salpingo-oophorectomy is inappropriate because radical surgery is unnecessary before less invasive drainage in this stable premenopausal patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop antibiotics and aspirate the abscess only if it ruptures is inappropriate because waiting for rupture risks peritonitis, septic shock, and emergent radical surgery."
        }
      }
    },
    {
      "externalId": "d5-expansion-hematology-acquired-hemophilia-a-001",
      "expectedHashes": {
        "ranaze_step3_uat": "d170fc50514b2992d2c48737fde90e59e065780ec4c19352b3a69526aa860038",
        "ranaze_step3_prd": "d170fc50514b2992d2c48737fde90e59e065780ec4c19352b3a69526aa860038"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Desmopressin followed by observation for spontaneous postpartum resolution is inappropriate because desmopressin is less effective than bypassing agents in acquired hemophilia and is inadequate for this major active bleed."
            },
            {
              "id": "B",
              "text": "Option C: High-dose human factor VIII concentrate as sole therapy is inappropriate because a high-titer inhibitor rapidly neutralizes human factor VIII; human factor VIII alone is inferior to bypassing agents or recombinant porcine factor VIII."
            },
            {
              "id": "C",
              "text": "Option D: Protamine sulfate followed by intravenous unfractionated heparin is inappropriate because there is no heparin exposure to reverse, and anticoagulation would worsen active hemorrhage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Desmopressin followed by observation for spontaneous postpartum resolution is inappropriate because desmopressin is less effective than bypassing agents in acquired hemophilia and is inadequate for this major active bleed."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose human factor VIII concentrate as sole therapy is inappropriate because a high-titer inhibitor rapidly neutralizes human factor VIII; human factor VIII alone is inferior to bypassing agents or recombinant porcine factor VIII."
            },
            {
              "id": "B",
              "text": "Option B: Desmopressin followed by observation for spontaneous postpartum resolution is inappropriate because desmopressin is less effective than bypassing agents in acquired hemophilia and is inadequate for this major active bleed."
            },
            {
              "id": "C",
              "text": "Option D: Protamine sulfate followed by intravenous unfractionated heparin is inappropriate because there is no heparin exposure to reverse, and anticoagulation would worsen active hemorrhage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose human factor VIII concentrate as sole therapy is inappropriate because a high-titer inhibitor rapidly neutralizes human factor VIII; human factor VIII alone is inferior to bypassing agents or recombinant porcine factor VIII."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Protamine sulfate followed by intravenous unfractionated heparin is inappropriate because there is no heparin exposure to reverse, and anticoagulation would worsen active hemorrhage."
            },
            {
              "id": "B",
              "text": "Option B: Desmopressin followed by observation for spontaneous postpartum resolution is inappropriate because desmopressin is less effective than bypassing agents in acquired hemophilia and is inadequate for this major active bleed."
            },
            {
              "id": "C",
              "text": "Option C: High-dose human factor VIII concentrate as sole therapy is inappropriate because a high-titer inhibitor rapidly neutralizes human factor VIII; human factor VIII alone is inferior to bypassing agents or recombinant porcine factor VIII."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Protamine sulfate followed by intravenous unfractionated heparin is inappropriate because there is no heparin exposure to reverse, and anticoagulation would worsen active hemorrhage."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Platelet transfusion plus intravenous immune globulin is inappropriate because the platelet count is normal and this is neither thrombocytopenia nor platelet-directed immune destruction."
            },
            {
              "id": "B",
              "text": "Option B: Desmopressin followed by observation for spontaneous postpartum resolution is inappropriate because desmopressin is less effective than bypassing agents in acquired hemophilia and is inadequate for this major active bleed."
            },
            {
              "id": "C",
              "text": "Option C: High-dose human factor VIII concentrate as sole therapy is inappropriate because a high-titer inhibitor rapidly neutralizes human factor VIII; human factor VIII alone is inferior to bypassing agents or recombinant porcine factor VIII."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Platelet transfusion plus intravenous immune globulin is inappropriate because the platelet count is normal and this is neither thrombocytopenia nor platelet-directed immune destruction."
        }
      }
    },
    {
      "externalId": "d5-expansion-hematology-pnh-budd-chiari-001",
      "expectedHashes": {
        "ranaze_step3_uat": "df0a996b656a00571146ff1082c383044a5186ec47a5c842770cf09ff1d44409",
        "ranaze_step3_prd": "df0a996b656a00571146ff1082c383044a5186ec47a5c842770cf09ff1d44409"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Therapeutic anticoagulation alone until hemolysis resolves spontaneously is inappropriate because anticoagulation alone leaves uncontrolled complement-mediated hemolysis and thrombophilia; spontaneous resolution should not be expected."
            },
            {
              "id": "B",
              "text": "Option C: Eculizumab alone because anticoagulation is contraindicated by thrombocytopenia is inappropriate because a platelet count above 80,000/mm\u00B3 without bleeding is not an absolute contraindication to anticoagulation in this life-threatening thrombosis."
            },
            {
              "id": "C",
              "text": "Option D: High-dose glucocorticoids and splenectomy is inappropriate because steroids and splenectomy do not correct the GPI-anchor defect or adequately control PNH thrombosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Therapeutic anticoagulation alone until hemolysis resolves spontaneously is inappropriate because anticoagulation alone leaves uncontrolled complement-mediated hemolysis and thrombophilia; spontaneous resolution should not be expected."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Eculizumab alone because anticoagulation is contraindicated by thrombocytopenia is inappropriate because a platelet count above 80,000/mm\u00B3 without bleeding is not an absolute contraindication to anticoagulation in this life-threatening thrombosis."
            },
            {
              "id": "B",
              "text": "Option B: Therapeutic anticoagulation alone until hemolysis resolves spontaneously is inappropriate because anticoagulation alone leaves uncontrolled complement-mediated hemolysis and thrombophilia; spontaneous resolution should not be expected."
            },
            {
              "id": "C",
              "text": "Option D: High-dose glucocorticoids and splenectomy is inappropriate because steroids and splenectomy do not correct the GPI-anchor defect or adequately control PNH thrombosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Eculizumab alone because anticoagulation is contraindicated by thrombocytopenia is inappropriate because a platelet count above 80,000/mm\u00B3 without bleeding is not an absolute contraindication to anticoagulation in this life-threatening thrombosis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose glucocorticoids and splenectomy is inappropriate because steroids and splenectomy do not correct the GPI-anchor defect or adequately control PNH thrombosis."
            },
            {
              "id": "B",
              "text": "Option B: Therapeutic anticoagulation alone until hemolysis resolves spontaneously is inappropriate because anticoagulation alone leaves uncontrolled complement-mediated hemolysis and thrombophilia; spontaneous resolution should not be expected."
            },
            {
              "id": "C",
              "text": "Option C: Eculizumab alone because anticoagulation is contraindicated by thrombocytopenia is inappropriate because a platelet count above 80,000/mm\u00B3 without bleeding is not an absolute contraindication to anticoagulation in this life-threatening thrombosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose glucocorticoids and splenectomy is inappropriate because steroids and splenectomy do not correct the GPI-anchor defect or adequately control PNH thrombosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plasma infusion to replace deficient complement-regulatory proteins is inappropriate because plasma does not restore cell-surface CD55/CD59 and can supply complement substrate, potentially worsening hemolysis during complement blockade."
            },
            {
              "id": "B",
              "text": "Option B: Therapeutic anticoagulation alone until hemolysis resolves spontaneously is inappropriate because anticoagulation alone leaves uncontrolled complement-mediated hemolysis and thrombophilia; spontaneous resolution should not be expected."
            },
            {
              "id": "C",
              "text": "Option C: Eculizumab alone because anticoagulation is contraindicated by thrombocytopenia is inappropriate because a platelet count above 80,000/mm\u00B3 without bleeding is not an absolute contraindication to anticoagulation in this life-threatening thrombosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plasma infusion to replace deficient complement-regulatory proteins is inappropriate because plasma does not restore cell-surface CD55/CD59 and can supply complement substrate, potentially worsening hemolysis during complement blockade."
        }
      }
    },
    {
      "externalId": "d5-expansion-hematology-severe-acute-chest-exchange-001",
      "expectedHashes": {
        "ranaze_step3_uat": "05141ca60ead26aa20af3febc49dcae2b7574bda2a8aadcf731b03e8a992fa45",
        "ranaze_step3_prd": "05141ca60ead26aa20af3febc49dcae2b7574bda2a8aadcf731b03e8a992fa45"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Simple transfusion of 3 units of packed red cells is inappropriate because adding 3 units at a hemoglobin of 9.4 g/dL risks hyperviscosity and reduces HbS less efficiently than exchange."
            },
            {
              "id": "B",
              "text": "Option C: Continue current therapy without transfusion for 24 hours is inappropriate because worsening hypoxemia and multilobar disease despite initial treatment define progression requiring urgent escalation."
            },
            {
              "id": "C",
              "text": "Option D: Immediate therapeutic anticoagulation for presumed pulmonary embolism is inappropriate because pulmonary embolism can be considered, but the new infiltrates and classic evolution establish acute chest syndrome; empiric anticoagulation does not treat it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Simple transfusion of 3 units of packed red cells is inappropriate because adding 3 units at a hemoglobin of 9.4 g/dL risks hyperviscosity and reduces HbS less efficiently than exchange."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue current therapy without transfusion for 24 hours is inappropriate because worsening hypoxemia and multilobar disease despite initial treatment define progression requiring urgent escalation."
            },
            {
              "id": "B",
              "text": "Option B: Simple transfusion of 3 units of packed red cells is inappropriate because adding 3 units at a hemoglobin of 9.4 g/dL risks hyperviscosity and reduces HbS less efficiently than exchange."
            },
            {
              "id": "C",
              "text": "Option D: Immediate therapeutic anticoagulation for presumed pulmonary embolism is inappropriate because pulmonary embolism can be considered, but the new infiltrates and classic evolution establish acute chest syndrome; empiric anticoagulation does not treat it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue current therapy without transfusion for 24 hours is inappropriate because worsening hypoxemia and multilobar disease despite initial treatment define progression requiring urgent escalation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate therapeutic anticoagulation for presumed pulmonary embolism is inappropriate because pulmonary embolism can be considered, but the new infiltrates and classic evolution establish acute chest syndrome; empiric anticoagulation does not treat it."
            },
            {
              "id": "B",
              "text": "Option B: Simple transfusion of 3 units of packed red cells is inappropriate because adding 3 units at a hemoglobin of 9.4 g/dL risks hyperviscosity and reduces HbS less efficiently than exchange."
            },
            {
              "id": "C",
              "text": "Option C: Continue current therapy without transfusion for 24 hours is inappropriate because worsening hypoxemia and multilobar disease despite initial treatment define progression requiring urgent escalation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate therapeutic anticoagulation for presumed pulmonary embolism is inappropriate because pulmonary embolism can be considered, but the new infiltrates and classic evolution establish acute chest syndrome; empiric anticoagulation does not treat it."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose intravenous glucocorticoids as definitive therapy is inappropriate because glucocorticoids are not definitive treatment for severe acute chest syndrome and may increase rebound vaso-occlusive complications."
            },
            {
              "id": "B",
              "text": "Option B: Simple transfusion of 3 units of packed red cells is inappropriate because adding 3 units at a hemoglobin of 9.4 g/dL risks hyperviscosity and reduces HbS less efficiently than exchange."
            },
            {
              "id": "C",
              "text": "Option C: Continue current therapy without transfusion for 24 hours is inappropriate because worsening hypoxemia and multilobar disease despite initial treatment define progression requiring urgent escalation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose intravenous glucocorticoids as definitive therapy is inappropriate because glucocorticoids are not definitive treatment for severe acute chest syndrome and may increase rebound vaso-occlusive complications."
        }
      }
    },
    {
      "externalId": "d5-expansion-musculoskeletal-clostridial-myonecrosis-001",
      "expectedHashes": {
        "ranaze_step3_uat": "3394b8d527d1fc9f26af219fcee765ffe7750dc96e0a49f180ea160bdeef6bf3",
        "ranaze_step3_prd": "3394b8d527d1fc9f26af219fcee765ffe7750dc96e0a49f180ea160bdeef6bf3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfer for hyperbaric oxygen therapy before further surgery is inappropriate because hyperbaric oxygen is not proven to improve outcomes and transfer can fatally delay debridement."
            },
            {
              "id": "B",
              "text": "Option C: Await Gram stain and culture results before selecting therapy is inappropriate because the clinical syndrome mandates treatment before microbiologic confirmation."
            },
            {
              "id": "C",
              "text": "Option D: Administer high-dose intravenous immune globulin without reoperation is inappropriate because iVIG is not standard definitive therapy for clostridial myonecrosis and cannot replace debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfer for hyperbaric oxygen therapy before further surgery is inappropriate because hyperbaric oxygen is not proven to improve outcomes and transfer can fatally delay debridement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Await Gram stain and culture results before selecting therapy is inappropriate because the clinical syndrome mandates treatment before microbiologic confirmation."
            },
            {
              "id": "B",
              "text": "Option B: Transfer for hyperbaric oxygen therapy before further surgery is inappropriate because hyperbaric oxygen is not proven to improve outcomes and transfer can fatally delay debridement."
            },
            {
              "id": "C",
              "text": "Option D: Administer high-dose intravenous immune globulin without reoperation is inappropriate because iVIG is not standard definitive therapy for clostridial myonecrosis and cannot replace debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Await Gram stain and culture results before selecting therapy is inappropriate because the clinical syndrome mandates treatment before microbiologic confirmation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer high-dose intravenous immune globulin without reoperation is inappropriate because iVIG is not standard definitive therapy for clostridial myonecrosis and cannot replace debridement."
            },
            {
              "id": "B",
              "text": "Option B: Transfer for hyperbaric oxygen therapy before further surgery is inappropriate because hyperbaric oxygen is not proven to improve outcomes and transfer can fatally delay debridement."
            },
            {
              "id": "C",
              "text": "Option C: Await Gram stain and culture results before selecting therapy is inappropriate because the clinical syndrome mandates treatment before microbiologic confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer high-dose intravenous immune globulin without reoperation is inappropriate because iVIG is not standard definitive therapy for clostridial myonecrosis and cannot replace debridement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform angiography to exclude arterial occlusion before wound exploration is inappropriate because gas within muscle after a contaminated wound with toxemia is sufficient to proceed; angiography would delay source control."
            },
            {
              "id": "B",
              "text": "Option B: Transfer for hyperbaric oxygen therapy before further surgery is inappropriate because hyperbaric oxygen is not proven to improve outcomes and transfer can fatally delay debridement."
            },
            {
              "id": "C",
              "text": "Option C: Await Gram stain and culture results before selecting therapy is inappropriate because the clinical syndrome mandates treatment before microbiologic confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform angiography to exclude arterial occlusion before wound exploration is inappropriate because gas within muscle after a contaminated wound with toxemia is sufficient to proceed; angiography would delay source control."
        }
      }
    },
    {
      "externalId": "d5-expansion-musculoskeletal-pyogenic-flexor-tenosynovitis-001",
      "expectedHashes": {
        "ranaze_step3_uat": "753029086c6054d648085795c39c97a20ab27d2e2525afbc35ed5e7310e9cb76",
        "ranaze_step3_prd": "753029086c6054d648085795c39c97a20ab27d2e2525afbc35ed5e7310e9cb76"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immobilization and intravenous antibiotics alone with reassessment in 72 hours is inappropriate because antibiotics alone with delayed reassessment risks tendon necrosis and loss of function in advanced disease."
            },
            {
              "id": "B",
              "text": "Option C: Ultrasound-guided needle aspiration of the tendon sheath is inappropriate because needle aspiration does not adequately irrigate or debride the long, loculated flexor sheath."
            },
            {
              "id": "C",
              "text": "Option D: Intra-articular glucocorticoid injection is inappropriate because glucocorticoid injection into an infected closed space can accelerate infection and tissue destruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immobilization and intravenous antibiotics alone with reassessment in 72 hours is inappropriate because antibiotics alone with delayed reassessment risks tendon necrosis and loss of function in advanced disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ultrasound-guided needle aspiration of the tendon sheath is inappropriate because needle aspiration does not adequately irrigate or debride the long, loculated flexor sheath."
            },
            {
              "id": "B",
              "text": "Option B: Immobilization and intravenous antibiotics alone with reassessment in 72 hours is inappropriate because antibiotics alone with delayed reassessment risks tendon necrosis and loss of function in advanced disease."
            },
            {
              "id": "C",
              "text": "Option D: Intra-articular glucocorticoid injection is inappropriate because glucocorticoid injection into an infected closed space can accelerate infection and tissue destruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ultrasound-guided needle aspiration of the tendon sheath is inappropriate because needle aspiration does not adequately irrigate or debride the long, loculated flexor sheath."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intra-articular glucocorticoid injection is inappropriate because glucocorticoid injection into an infected closed space can accelerate infection and tissue destruction."
            },
            {
              "id": "B",
              "text": "Option B: Immobilization and intravenous antibiotics alone with reassessment in 72 hours is inappropriate because antibiotics alone with delayed reassessment risks tendon necrosis and loss of function in advanced disease."
            },
            {
              "id": "C",
              "text": "Option C: Ultrasound-guided needle aspiration of the tendon sheath is inappropriate because needle aspiration does not adequately irrigate or debride the long, loculated flexor sheath."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intra-articular glucocorticoid injection is inappropriate because glucocorticoid injection into an infected closed space can accelerate infection and tissue destruction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate amputation of the index finger is inappropriate because amputation is reserved for nonviable or unsalvageable tissue; prompt debridement may preserve the digit."
            },
            {
              "id": "B",
              "text": "Option B: Immobilization and intravenous antibiotics alone with reassessment in 72 hours is inappropriate because antibiotics alone with delayed reassessment risks tendon necrosis and loss of function in advanced disease."
            },
            {
              "id": "C",
              "text": "Option C: Ultrasound-guided needle aspiration of the tendon sheath is inappropriate because needle aspiration does not adequately irrigate or debride the long, loculated flexor sheath."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate amputation of the index finger is inappropriate because amputation is reserved for nonviable or unsalvageable tissue; prompt debridement may preserve the digit."
        }
      }
    },
    {
      "externalId": "d5-expansion-musculoskeletal-type-iii-open-fracture-sequence-001",
      "expectedHashes": {
        "ranaze_step3_uat": "dc2af28a08cbe4c89a32d078d8a7bd3e688a995ce5a951d06c4e585d57f3f1a6",
        "ranaze_step3_prd": "dc2af28a08cbe4c89a32d078d8a7bd3e688a995ce5a951d06c4e585d57f3f1a6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain deep wound cultures first, then withhold antibiotics until culture results guide treatment is inappropriate because open-fracture antibiotics are prophylactic and time-sensitive; superficial or pre-debridement cultures should not delay them."
            },
            {
              "id": "B",
              "text": "Option C: Irrigate the wound extensively in the emergency department, close it primarily, and prescribe oral cephalexin is inappropriate because eD irrigation and premature closure can drive contamination deeper and leave devitalized tissue untreated."
            },
            {
              "id": "C",
              "text": "Option D: Proceed directly to internal fixation and delay antibiotics until after operative cultures are obtained is inappropriate because delayed antibiotics increase infection risk, and fixation strategy follows adequate irrigation and debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain deep wound cultures first, then withhold antibiotics until culture results guide treatment is inappropriate because open-fracture antibiotics are prophylactic and time-sensitive; superficial or pre-debridement cultures should not delay them."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Irrigate the wound extensively in the emergency department, close it primarily, and prescribe oral cephalexin is inappropriate because eD irrigation and premature closure can drive contamination deeper and leave devitalized tissue untreated."
            },
            {
              "id": "B",
              "text": "Option B: Obtain deep wound cultures first, then withhold antibiotics until culture results guide treatment is inappropriate because open-fracture antibiotics are prophylactic and time-sensitive; superficial or pre-debridement cultures should not delay them."
            },
            {
              "id": "C",
              "text": "Option D: Proceed directly to internal fixation and delay antibiotics until after operative cultures are obtained is inappropriate because delayed antibiotics increase infection risk, and fixation strategy follows adequate irrigation and debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Irrigate the wound extensively in the emergency department, close it primarily, and prescribe oral cephalexin is inappropriate because eD irrigation and premature closure can drive contamination deeper and leave devitalized tissue untreated."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly to internal fixation and delay antibiotics until after operative cultures are obtained is inappropriate because delayed antibiotics increase infection risk, and fixation strategy follows adequate irrigation and debridement."
            },
            {
              "id": "B",
              "text": "Option B: Obtain deep wound cultures first, then withhold antibiotics until culture results guide treatment is inappropriate because open-fracture antibiotics are prophylactic and time-sensitive; superficial or pre-debridement cultures should not delay them."
            },
            {
              "id": "C",
              "text": "Option C: Irrigate the wound extensively in the emergency department, close it primarily, and prescribe oral cephalexin is inappropriate because eD irrigation and premature closure can drive contamination deeper and leave devitalized tissue untreated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly to internal fixation and delay antibiotics until after operative cultures are obtained is inappropriate because delayed antibiotics increase infection risk, and fixation strategy follows adequate irrigation and debridement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give tetanus immune globulin alone and schedule debridement after 48 hours of intravenous antibiotics is inappropriate because tIG does not create durable immunity, and a grossly contaminated open fracture requires prompt\u2014not delayed\u2014operative source control."
            },
            {
              "id": "B",
              "text": "Option B: Obtain deep wound cultures first, then withhold antibiotics until culture results guide treatment is inappropriate because open-fracture antibiotics are prophylactic and time-sensitive; superficial or pre-debridement cultures should not delay them."
            },
            {
              "id": "C",
              "text": "Option C: Irrigate the wound extensively in the emergency department, close it primarily, and prescribe oral cephalexin is inappropriate because eD irrigation and premature closure can drive contamination deeper and leave devitalized tissue untreated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give tetanus immune globulin alone and schedule debridement after 48 hours of intravenous antibiotics is inappropriate because tIG does not create durable immunity, and a grossly contaminated open fracture requires prompt\u2014not delayed\u2014operative source control."
        }
      }
    },
    {
      "externalId": "d5-expansion-neurology-anti-nmdar-teratoma-immunotherapy-001",
      "expectedHashes": {
        "ranaze_step3_uat": "ae14d1f9918afee3d1dcfdd57edf3cd9ad75cadc43e041beb4ea5aa56e23af85",
        "ranaze_step3_prd": "ae14d1f9918afee3d1dcfdd57edf3cd9ad75cadc43e041beb4ea5aa56e23af85"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Antipsychotic monotherapy until the psychiatric symptoms remit, followed by elective tumor resection is inappropriate because psychiatric medication alone does not treat the autoimmune process, and delaying teratoma removal worsens the chance of timely recovery."
            },
            {
              "id": "B",
              "text": "Option C: Acyclovir alone for 21 days despite the negative HSV evaluation is inappropriate because empiric acyclovir is reasonable while HSV is being excluded, but it is not definitive therapy after this diagnosis is established."
            },
            {
              "id": "C",
              "text": "Option D: Immediate whole-brain radiation therapy followed by cyclophosphamide is inappropriate because a benign ovarian teratoma is surgically removed; whole-brain radiation has no role."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Antipsychotic monotherapy until the psychiatric symptoms remit, followed by elective tumor resection is inappropriate because psychiatric medication alone does not treat the autoimmune process, and delaying teratoma removal worsens the chance of timely recovery."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acyclovir alone for 21 days despite the negative HSV evaluation is inappropriate because empiric acyclovir is reasonable while HSV is being excluded, but it is not definitive therapy after this diagnosis is established."
            },
            {
              "id": "B",
              "text": "Option B: Antipsychotic monotherapy until the psychiatric symptoms remit, followed by elective tumor resection is inappropriate because psychiatric medication alone does not treat the autoimmune process, and delaying teratoma removal worsens the chance of timely recovery."
            },
            {
              "id": "C",
              "text": "Option D: Immediate whole-brain radiation therapy followed by cyclophosphamide is inappropriate because a benign ovarian teratoma is surgically removed; whole-brain radiation has no role."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acyclovir alone for 21 days despite the negative HSV evaluation is inappropriate because empiric acyclovir is reasonable while HSV is being excluded, but it is not definitive therapy after this diagnosis is established."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate whole-brain radiation therapy followed by cyclophosphamide is inappropriate because a benign ovarian teratoma is surgically removed; whole-brain radiation has no role."
            },
            {
              "id": "B",
              "text": "Option B: Antipsychotic monotherapy until the psychiatric symptoms remit, followed by elective tumor resection is inappropriate because psychiatric medication alone does not treat the autoimmune process, and delaying teratoma removal worsens the chance of timely recovery."
            },
            {
              "id": "C",
              "text": "Option C: Acyclovir alone for 21 days despite the negative HSV evaluation is inappropriate because empiric acyclovir is reasonable while HSV is being excluded, but it is not definitive therapy after this diagnosis is established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate whole-brain radiation therapy followed by cyclophosphamide is inappropriate because a benign ovarian teratoma is surgically removed; whole-brain radiation has no role."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay immunotherapy until the serum antibody titer rises on serial testing is inappropriate because serial antibody titers should not delay treatment and correlate imperfectly with moment-to-moment disease activity."
            },
            {
              "id": "B",
              "text": "Option B: Antipsychotic monotherapy until the psychiatric symptoms remit, followed by elective tumor resection is inappropriate because psychiatric medication alone does not treat the autoimmune process, and delaying teratoma removal worsens the chance of timely recovery."
            },
            {
              "id": "C",
              "text": "Option C: Acyclovir alone for 21 days despite the negative HSV evaluation is inappropriate because empiric acyclovir is reasonable while HSV is being excluded, but it is not definitive therapy after this diagnosis is established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay immunotherapy until the serum antibody titer rises on serial testing is inappropriate because serial antibody titers should not delay treatment and correlate imperfectly with moment-to-moment disease activity."
        }
      }
    },
    {
      "externalId": "d5-expansion-neurology-cvt-hemorrhagic-infarct-anticoagulation-001",
      "expectedHashes": {
        "ranaze_step3_uat": "ecdb33ee08c1dbca2e364d8a46cd899a4541b83b39ad01472a6777b6665062e5",
        "ranaze_step3_prd": "ecdb33ee08c1dbca2e364d8a46cd899a4541b83b39ad01472a6777b6665062e5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold anticoagulation and repeat noncontrast CT in 7 days is inappropriate because observation permits thrombus propagation and worsening venous congestion."
            },
            {
              "id": "B",
              "text": "Option C: Administer intravenous alteplase using the acute arterial-stroke protocol is inappropriate because systemic alteplase for arterial ischemic stroke is not routine treatment for CVT with hemorrhagic infarction."
            },
            {
              "id": "C",
              "text": "Option D: Perform immediate endovascular thrombectomy as routine first-line therapy is inappropriate because endovascular rescue is not routine first-line therapy in a neurologically stable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold anticoagulation and repeat noncontrast CT in 7 days is inappropriate because observation permits thrombus propagation and worsening venous congestion."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous alteplase using the acute arterial-stroke protocol is inappropriate because systemic alteplase for arterial ischemic stroke is not routine treatment for CVT with hemorrhagic infarction."
            },
            {
              "id": "B",
              "text": "Option B: Withhold anticoagulation and repeat noncontrast CT in 7 days is inappropriate because observation permits thrombus propagation and worsening venous congestion."
            },
            {
              "id": "C",
              "text": "Option D: Perform immediate endovascular thrombectomy as routine first-line therapy is inappropriate because endovascular rescue is not routine first-line therapy in a neurologically stable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous alteplase using the acute arterial-stroke protocol is inappropriate because systemic alteplase for arterial ischemic stroke is not routine treatment for CVT with hemorrhagic infarction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate endovascular thrombectomy as routine first-line therapy is inappropriate because endovascular rescue is not routine first-line therapy in a neurologically stable patient."
            },
            {
              "id": "B",
              "text": "Option B: Withhold anticoagulation and repeat noncontrast CT in 7 days is inappropriate because observation permits thrombus propagation and worsening venous congestion."
            },
            {
              "id": "C",
              "text": "Option C: Administer intravenous alteplase using the acute arterial-stroke protocol is inappropriate because systemic alteplase for arterial ischemic stroke is not routine treatment for CVT with hemorrhagic infarction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate endovascular thrombectomy as routine first-line therapy is inappropriate because endovascular rescue is not routine first-line therapy in a neurologically stable patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start aspirin alone because anticoagulation is contraindicated after intracranial bleeding is inappropriate because aspirin is inadequate treatment for acute CVT, and the venous hemorrhage is not itself a contraindication to anticoagulation."
            },
            {
              "id": "B",
              "text": "Option B: Withhold anticoagulation and repeat noncontrast CT in 7 days is inappropriate because observation permits thrombus propagation and worsening venous congestion."
            },
            {
              "id": "C",
              "text": "Option C: Administer intravenous alteplase using the acute arterial-stroke protocol is inappropriate because systemic alteplase for arterial ischemic stroke is not routine treatment for CVT with hemorrhagic infarction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start aspirin alone because anticoagulation is contraindicated after intracranial bleeding is inappropriate because aspirin is inadequate treatment for acute CVT, and the venous hemorrhage is not itself a contraindication to anticoagulation."
        }
      }
    },
    {
      "externalId": "d5-expansion-neurology-malignant-mca-early-hemicraniectomy-001",
      "expectedHashes": {
        "ranaze_step3_uat": "e8791dda6b4694f3d20fa0bf9218088e9d39253a5cc11764631ee91a73bdeaf8",
        "ranaze_step3_prd": "e8791dda6b4694f3d20fa0bf9218088e9d39253a5cc11764631ee91a73bdeaf8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue scheduled mannitol for 5 days and operate only after a pupil becomes fixed is inappropriate because hyperosmolar therapy is temporary rescue; waiting for pupillary fixation dangerously delays decompression."
            },
            {
              "id": "B",
              "text": "Option C: Administer high-dose dexamethasone to reduce cytotoxic edema is inappropriate because corticosteroids do not improve cytotoxic edema from ischemic stroke and can cause harm."
            },
            {
              "id": "C",
              "text": "Option D: Perform prophylactic therapeutic hypothermia for 72 hours is inappropriate because routine prophylactic hypothermia has no established outcome benefit and carries substantial complications."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue scheduled mannitol for 5 days and operate only after a pupil becomes fixed is inappropriate because hyperosmolar therapy is temporary rescue; waiting for pupillary fixation dangerously delays decompression."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer high-dose dexamethasone to reduce cytotoxic edema is inappropriate because corticosteroids do not improve cytotoxic edema from ischemic stroke and can cause harm."
            },
            {
              "id": "B",
              "text": "Option B: Continue scheduled mannitol for 5 days and operate only after a pupil becomes fixed is inappropriate because hyperosmolar therapy is temporary rescue; waiting for pupillary fixation dangerously delays decompression."
            },
            {
              "id": "C",
              "text": "Option D: Perform prophylactic therapeutic hypothermia for 72 hours is inappropriate because routine prophylactic hypothermia has no established outcome benefit and carries substantial complications."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer high-dose dexamethasone to reduce cytotoxic edema is inappropriate because corticosteroids do not improve cytotoxic edema from ischemic stroke and can cause harm."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform prophylactic therapeutic hypothermia for 72 hours is inappropriate because routine prophylactic hypothermia has no established outcome benefit and carries substantial complications."
            },
            {
              "id": "B",
              "text": "Option B: Continue scheduled mannitol for 5 days and operate only after a pupil becomes fixed is inappropriate because hyperosmolar therapy is temporary rescue; waiting for pupillary fixation dangerously delays decompression."
            },
            {
              "id": "C",
              "text": "Option C: Administer high-dose dexamethasone to reduce cytotoxic edema is inappropriate because corticosteroids do not improve cytotoxic edema from ischemic stroke and can cause harm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform prophylactic therapeutic hypothermia for 72 hours is inappropriate because routine prophylactic hypothermia has no established outcome benefit and carries substantial complications."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin comfort-focused care because surgery does not improve survival is inappropriate because surgery clearly reduces mortality; the disability tradeoff should be aligned with the patient\u0027s stated values."
            },
            {
              "id": "B",
              "text": "Option B: Continue scheduled mannitol for 5 days and operate only after a pupil becomes fixed is inappropriate because hyperosmolar therapy is temporary rescue; waiting for pupillary fixation dangerously delays decompression."
            },
            {
              "id": "C",
              "text": "Option C: Administer high-dose dexamethasone to reduce cytotoxic edema is inappropriate because corticosteroids do not improve cytotoxic edema from ischemic stroke and can cause harm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin comfort-focused care because surgery does not improve survival is inappropriate because surgery clearly reduces mortality; the disability tradeoff should be aligned with the patient\u0027s stated values."
        }
      }
    },
    {
      "externalId": "d5-expansion-nutrition-copper-deficiency-zinc-bypass-001",
      "expectedHashes": {
        "ranaze_step3_uat": "46b4b9126d2c5b7115f1de9e2c40c6ccd9f1dc25b5035f501d227e8f9e8934c4",
        "ranaze_step3_prd": "46b4b9126d2c5b7115f1de9e2c40c6ccd9f1dc25b5035f501d227e8f9e8934c4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase zinc because zinc and copper deficiencies are treated together is inappropriate because more zinc increases metallothionein-mediated copper loss."
            },
            {
              "id": "B",
              "text": "Option C: Give vitamin B12 injections alone despite normal methylmalonic acid is inappropriate because normal B12 and methylmalonic acid make isolated B12 deficiency unlikely; B12 will not correct copper depletion."
            },
            {
              "id": "C",
              "text": "Option D: Start high-dose folic acid alone and reassess in 1 year is inappropriate because folate does not explain the low copper or posterior-column syndrome and can delay the correct treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase zinc because zinc and copper deficiencies are treated together is inappropriate because more zinc increases metallothionein-mediated copper loss."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give vitamin B12 injections alone despite normal methylmalonic acid is inappropriate because normal B12 and methylmalonic acid make isolated B12 deficiency unlikely; B12 will not correct copper depletion."
            },
            {
              "id": "B",
              "text": "Option B: Increase zinc because zinc and copper deficiencies are treated together is inappropriate because more zinc increases metallothionein-mediated copper loss."
            },
            {
              "id": "C",
              "text": "Option D: Start high-dose folic acid alone and reassess in 1 year is inappropriate because folate does not explain the low copper or posterior-column syndrome and can delay the correct treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give vitamin B12 injections alone despite normal methylmalonic acid is inappropriate because normal B12 and methylmalonic acid make isolated B12 deficiency unlikely; B12 will not correct copper depletion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start high-dose folic acid alone and reassess in 1 year is inappropriate because folate does not explain the low copper or posterior-column syndrome and can delay the correct treatment."
            },
            {
              "id": "B",
              "text": "Option B: Increase zinc because zinc and copper deficiencies are treated together is inappropriate because more zinc increases metallothionein-mediated copper loss."
            },
            {
              "id": "C",
              "text": "Option C: Give vitamin B12 injections alone despite normal methylmalonic acid is inappropriate because normal B12 and methylmalonic acid make isolated B12 deficiency unlikely; B12 will not correct copper depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start high-dose folic acid alone and reassess in 1 year is inappropriate because folate does not explain the low copper or posterior-column syndrome and can delay the correct treatment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform urgent cervical decompression surgery is inappropriate because the symmetric nutritional myelopathy lacks a compressive lesion."
            },
            {
              "id": "B",
              "text": "Option B: Increase zinc because zinc and copper deficiencies are treated together is inappropriate because more zinc increases metallothionein-mediated copper loss."
            },
            {
              "id": "C",
              "text": "Option C: Give vitamin B12 injections alone despite normal methylmalonic acid is inappropriate because normal B12 and methylmalonic acid make isolated B12 deficiency unlikely; B12 will not correct copper depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform urgent cervical decompression surgery is inappropriate because the symmetric nutritional myelopathy lacks a compressive lesion."
        }
      }
    },
    {
      "externalId": "d5-expansion-nutrition-d-lactic-short-bowel-encephalopathy-001",
      "expectedHashes": {
        "ranaze_step3_uat": "2c6f163f1ef531d0af01ff0bc2c50b8e11df1f95565246abcdd1b5639971b2b3",
        "ranaze_step3_prd": "2c6f163f1ef531d0af01ff0bc2c50b8e11df1f95565246abcdd1b5639971b2b3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer high-dose insulin for occult diabetic ketoacidosis is inappropriate because normal glucose and the characteristic postprandial short-bowel pattern argue strongly against DKA."
            },
            {
              "id": "B",
              "text": "Option C: Start lifelong anticoagulation for recurrent posterior-circulation ischemia is inappropriate because the recurring meal-linked metabolic episodes are not transient ischemic attacks."
            },
            {
              "id": "C",
              "text": "Option D: Increase oral simple carbohydrates to improve cerebral glucose delivery is inappropriate because additional simple carbohydrate supplies more substrate for bacterial D-lactate production."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer high-dose insulin for occult diabetic ketoacidosis is inappropriate because normal glucose and the characteristic postprandial short-bowel pattern argue strongly against DKA."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start lifelong anticoagulation for recurrent posterior-circulation ischemia is inappropriate because the recurring meal-linked metabolic episodes are not transient ischemic attacks."
            },
            {
              "id": "B",
              "text": "Option B: Administer high-dose insulin for occult diabetic ketoacidosis is inappropriate because normal glucose and the characteristic postprandial short-bowel pattern argue strongly against DKA."
            },
            {
              "id": "C",
              "text": "Option D: Increase oral simple carbohydrates to improve cerebral glucose delivery is inappropriate because additional simple carbohydrate supplies more substrate for bacterial D-lactate production."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start lifelong anticoagulation for recurrent posterior-circulation ischemia is inappropriate because the recurring meal-linked metabolic episodes are not transient ischemic attacks."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase oral simple carbohydrates to improve cerebral glucose delivery is inappropriate because additional simple carbohydrate supplies more substrate for bacterial D-lactate production."
            },
            {
              "id": "B",
              "text": "Option B: Administer high-dose insulin for occult diabetic ketoacidosis is inappropriate because normal glucose and the characteristic postprandial short-bowel pattern argue strongly against DKA."
            },
            {
              "id": "C",
              "text": "Option C: Start lifelong anticoagulation for recurrent posterior-circulation ischemia is inappropriate because the recurring meal-linked metabolic episodes are not transient ischemic attacks."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase oral simple carbohydrates to improve cerebral glucose delivery is inappropriate because additional simple carbohydrate supplies more substrate for bacterial D-lactate production."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform emergent colectomy during the acute episode is inappropriate because colectomy can abolish the production site but is not routine acute therapy and sacrifices absorptive benefit."
            },
            {
              "id": "B",
              "text": "Option B: Administer high-dose insulin for occult diabetic ketoacidosis is inappropriate because normal glucose and the characteristic postprandial short-bowel pattern argue strongly against DKA."
            },
            {
              "id": "C",
              "text": "Option C: Start lifelong anticoagulation for recurrent posterior-circulation ischemia is inappropriate because the recurring meal-linked metabolic episodes are not transient ischemic attacks."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform emergent colectomy during the acute episode is inappropriate because colectomy can abolish the production site but is not routine acute therapy and sacrifices absorptive benefit."
        }
      }
    },
    {
      "externalId": "d5-expansion-nutrition-refeeding-prevention-sequence-001",
      "expectedHashes": {
        "ranaze_step3_uat": "e15ca0a503fa2696eef217781bdf9af7f05cffd8d5e27cf9db16ea37f1f6f6d6",
        "ranaze_step3_prd": "e15ca0a503fa2696eef217781bdf9af7f05cffd8d5e27cf9db16ea37f1f6f6d6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin full estimated caloric needs immediately and check electrolytes once after 72 hours is inappropriate because full feeding can precipitate severe electrolyte shifts before a 72-hour check."
            },
            {
              "id": "B",
              "text": "Option C: Withhold thiamine until neurologic symptoms develop because it can impair glucose utilization is inappropriate because thiamine is consumed during carbohydrate metabolism and must precede dextrose in a high-risk patient."
            },
            {
              "id": "C",
              "text": "Option D: Use parenteral nutrition at full calories because refeeding syndrome occurs only with enteral feeding is inappropriate because refeeding syndrome occurs with enteral, parenteral, or oral carbohydrate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin full estimated caloric needs immediately and check electrolytes once after 72 hours is inappropriate because full feeding can precipitate severe electrolyte shifts before a 72-hour check."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold thiamine until neurologic symptoms develop because it can impair glucose utilization is inappropriate because thiamine is consumed during carbohydrate metabolism and must precede dextrose in a high-risk patient."
            },
            {
              "id": "B",
              "text": "Option B: Begin full estimated caloric needs immediately and check electrolytes once after 72 hours is inappropriate because full feeding can precipitate severe electrolyte shifts before a 72-hour check."
            },
            {
              "id": "C",
              "text": "Option D: Use parenteral nutrition at full calories because refeeding syndrome occurs only with enteral feeding is inappropriate because refeeding syndrome occurs with enteral, parenteral, or oral carbohydrate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold thiamine until neurologic symptoms develop because it can impair glucose utilization is inappropriate because thiamine is consumed during carbohydrate metabolism and must precede dextrose in a high-risk patient."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use parenteral nutrition at full calories because refeeding syndrome occurs only with enteral feeding is inappropriate because refeeding syndrome occurs with enteral, parenteral, or oral carbohydrate."
            },
            {
              "id": "B",
              "text": "Option B: Begin full estimated caloric needs immediately and check electrolytes once after 72 hours is inappropriate because full feeding can precipitate severe electrolyte shifts before a 72-hour check."
            },
            {
              "id": "C",
              "text": "Option C: Withhold thiamine until neurologic symptoms develop because it can impair glucose utilization is inappropriate because thiamine is consumed during carbohydrate metabolism and must precede dextrose in a high-risk patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use parenteral nutrition at full calories because refeeding syndrome occurs only with enteral feeding is inappropriate because refeeding syndrome occurs with enteral, parenteral, or oral carbohydrate."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Correct phosphorus alone, then provide unrestricted dextrose without monitoring potassium or magnesium is inappropriate because phosphate is often most dramatic, but potassium and magnesium shifts are also lethal and require monitoring."
            },
            {
              "id": "B",
              "text": "Option B: Begin full estimated caloric needs immediately and check electrolytes once after 72 hours is inappropriate because full feeding can precipitate severe electrolyte shifts before a 72-hour check."
            },
            {
              "id": "C",
              "text": "Option C: Withhold thiamine until neurologic symptoms develop because it can impair glucose utilization is inappropriate because thiamine is consumed during carbohydrate metabolism and must precede dextrose in a high-risk patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Correct phosphorus alone, then provide unrestricted dextrose without monitoring potassium or magnesium is inappropriate because phosphate is often most dramatic, but potassium and magnesium shifts are also lethal and require monitoring."
        }
      }
    },
    {
      "externalId": "d5-expansion-obstetrics-amniotic-fluid-embolism-resuscitation-001",
      "expectedHashes": {
        "ranaze_step3_uat": "c32ee1205180117e2db15b7aa62de7c3360b7df98478c412e94d8f933686fd75",
        "ranaze_step3_prd": "c32ee1205180117e2db15b7aa62de7c3360b7df98478c412e94d8f933686fd75"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain serum tryptase and complement levels before initiating disease-specific treatment is inappropriate because aFE has no validated confirmatory laboratory test, and diagnostic testing must not delay resuscitation."
            },
            {
              "id": "B",
              "text": "Option C: Administer alteplase for presumed massive pulmonary thromboembolism before delivery is inappropriate because pulmonary embolism can cause collapse but does not typically cause immediate profound DIC; empiric thrombolysis would worsen this patient\u0027s hemorrhage."
            },
            {
              "id": "C",
              "text": "Option D: Give a rapid 4-L crystalloid bolus as the primary treatment for right ventricular failure is inappropriate because excessive crystalloid can worsen right ventricular failure and pulmonary edema; blood products and vasoactive support are prioritized."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain serum tryptase and complement levels before initiating disease-specific treatment is inappropriate because aFE has no validated confirmatory laboratory test, and diagnostic testing must not delay resuscitation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer alteplase for presumed massive pulmonary thromboembolism before delivery is inappropriate because pulmonary embolism can cause collapse but does not typically cause immediate profound DIC; empiric thrombolysis would worsen this patient\u0027s hemorrhage."
            },
            {
              "id": "B",
              "text": "Option B: Obtain serum tryptase and complement levels before initiating disease-specific treatment is inappropriate because aFE has no validated confirmatory laboratory test, and diagnostic testing must not delay resuscitation."
            },
            {
              "id": "C",
              "text": "Option D: Give a rapid 4-L crystalloid bolus as the primary treatment for right ventricular failure is inappropriate because excessive crystalloid can worsen right ventricular failure and pulmonary edema; blood products and vasoactive support are prioritized."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer alteplase for presumed massive pulmonary thromboembolism before delivery is inappropriate because pulmonary embolism can cause collapse but does not typically cause immediate profound DIC; empiric thrombolysis would worsen this patient\u0027s hemorrhage."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give a rapid 4-L crystalloid bolus as the primary treatment for right ventricular failure is inappropriate because excessive crystalloid can worsen right ventricular failure and pulmonary edema; blood products and vasoactive support are prioritized."
            },
            {
              "id": "B",
              "text": "Option B: Obtain serum tryptase and complement levels before initiating disease-specific treatment is inappropriate because aFE has no validated confirmatory laboratory test, and diagnostic testing must not delay resuscitation."
            },
            {
              "id": "C",
              "text": "Option C: Administer alteplase for presumed massive pulmonary thromboembolism before delivery is inappropriate because pulmonary embolism can cause collapse but does not typically cause immediate profound DIC; empiric thrombolysis would worsen this patient\u0027s hemorrhage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give a rapid 4-L crystalloid bolus as the primary treatment for right ventricular failure is inappropriate because excessive crystalloid can worsen right ventricular failure and pulmonary edema; blood products and vasoactive support are prioritized."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay delivery until return of spontaneous circulation has been sustained for 20 minutes is inappropriate because delivery should not await sustained return of spontaneous circulation when arrest persists and the fetus is viable."
            },
            {
              "id": "B",
              "text": "Option B: Obtain serum tryptase and complement levels before initiating disease-specific treatment is inappropriate because aFE has no validated confirmatory laboratory test, and diagnostic testing must not delay resuscitation."
            },
            {
              "id": "C",
              "text": "Option C: Administer alteplase for presumed massive pulmonary thromboembolism before delivery is inappropriate because pulmonary embolism can cause collapse but does not typically cause immediate profound DIC; empiric thrombolysis would worsen this patient\u0027s hemorrhage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay delivery until return of spontaneous circulation has been sustained for 20 minutes is inappropriate because delivery should not await sustained return of spontaneous circulation when arrest persists and the fetus is viable."
        }
      }
    },
    {
      "externalId": "d5-expansion-obstetrics-atony-balloon-tamponade-001",
      "expectedHashes": {
        "ranaze_step3_uat": "f74d664f3fdd8090a9ac14b5e3b3168d0d41d179cac3acf355d406d2f2e217a6",
        "ranaze_step3_prd": "f74d664f3fdd8090a9ac14b5e3b3168d0d41d179cac3acf355d406d2f2e217a6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform dilation and curettage for presumed retained placental tissue is inappropriate because curettage is used for retained products, which are not supported by the intact placenta and negative ultrasonography."
            },
            {
              "id": "B",
              "text": "Option C: Proceed directly to hysterectomy without attempting a conservative mechanical intervention is inappropriate because hysterectomy is lifesaving when conservative measures fail or the patient deteriorates, but balloon tamponade is appropriate before hysterectomy in this temporarily stabilized patient."
            },
            {
              "id": "C",
              "text": "Option D: Administer a second dose of tranexamic acid immediately, 15 minutes after the first is inappropriate because a repeat TXA dose may be considered if bleeding continues after 30 minutes or restarts within 24 hours, not routinely at 15 minutes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform dilation and curettage for presumed retained placental tissue is inappropriate because curettage is used for retained products, which are not supported by the intact placenta and negative ultrasonography."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly to hysterectomy without attempting a conservative mechanical intervention is inappropriate because hysterectomy is lifesaving when conservative measures fail or the patient deteriorates, but balloon tamponade is appropriate before hysterectomy in this temporarily stabilized patient."
            },
            {
              "id": "B",
              "text": "Option B: Perform dilation and curettage for presumed retained placental tissue is inappropriate because curettage is used for retained products, which are not supported by the intact placenta and negative ultrasonography."
            },
            {
              "id": "C",
              "text": "Option D: Administer a second dose of tranexamic acid immediately, 15 minutes after the first is inappropriate because a repeat TXA dose may be considered if bleeding continues after 30 minutes or restarts within 24 hours, not routinely at 15 minutes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly to hysterectomy without attempting a conservative mechanical intervention is inappropriate because hysterectomy is lifesaving when conservative measures fail or the patient deteriorates, but balloon tamponade is appropriate before hysterectomy in this temporarily stabilized patient."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a second dose of tranexamic acid immediately, 15 minutes after the first is inappropriate because a repeat TXA dose may be considered if bleeding continues after 30 minutes or restarts within 24 hours, not routinely at 15 minutes."
            },
            {
              "id": "B",
              "text": "Option B: Perform dilation and curettage for presumed retained placental tissue is inappropriate because curettage is used for retained products, which are not supported by the intact placenta and negative ultrasonography."
            },
            {
              "id": "C",
              "text": "Option C: Proceed directly to hysterectomy without attempting a conservative mechanical intervention is inappropriate because hysterectomy is lifesaving when conservative measures fail or the patient deteriorates, but balloon tamponade is appropriate before hysterectomy in this temporarily stabilized patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a second dose of tranexamic acid immediately, 15 minutes after the first is inappropriate because a repeat TXA dose may be considered if bleeding continues after 30 minutes or restarts within 24 hours, not routinely at 15 minutes."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe for 30 minutes because the patient is currently responsive is inappropriate because ongoing hemorrhage demands immediate source control even when transient resuscitation preserves mentation."
            },
            {
              "id": "B",
              "text": "Option B: Perform dilation and curettage for presumed retained placental tissue is inappropriate because curettage is used for retained products, which are not supported by the intact placenta and negative ultrasonography."
            },
            {
              "id": "C",
              "text": "Option C: Proceed directly to hysterectomy without attempting a conservative mechanical intervention is inappropriate because hysterectomy is lifesaving when conservative measures fail or the patient deteriorates, but balloon tamponade is appropriate before hysterectomy in this temporarily stabilized patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe for 30 minutes because the patient is currently responsive is inappropriate because ongoing hemorrhage demands immediate source control even when transient resuscitation preserves mentation."
        }
      }
    },
    {
      "externalId": "d5-expansion-obstetrics-hellp-ruptured-hepatic-hematoma-001",
      "expectedHashes": {
        "ranaze_step3_uat": "d0a4e8699989f0ed7467b4c5e26041592c64d609d0c92f695ddcee86b4a095cf",
        "ranaze_step3_prd": "d0a4e8699989f0ed7467b4c5e26041592c64d609d0c92f695ddcee86b4a095cf"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer dexamethasone and repeat hepatic imaging in 12 hours is inappropriate because corticosteroids do not control active intra-abdominal hemorrhage, and observation is unsafe after rupture."
            },
            {
              "id": "B",
              "text": "Option C: Give magnesium sulfate alone and continue pregnancy until 37 weeks is inappropriate because magnesium prevents eclamptic seizures but neither treats hemorrhagic shock nor justifies prolonging this pregnancy."
            },
            {
              "id": "C",
              "text": "Option D: Perform ultrasound-guided percutaneous aspiration of the subcapsular collection is inappropriate because percutaneous aspiration can release tamponade and worsen bleeding; ruptured hematoma requires vascular or operative control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer dexamethasone and repeat hepatic imaging in 12 hours is inappropriate because corticosteroids do not control active intra-abdominal hemorrhage, and observation is unsafe after rupture."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give magnesium sulfate alone and continue pregnancy until 37 weeks is inappropriate because magnesium prevents eclamptic seizures but neither treats hemorrhagic shock nor justifies prolonging this pregnancy."
            },
            {
              "id": "B",
              "text": "Option B: Administer dexamethasone and repeat hepatic imaging in 12 hours is inappropriate because corticosteroids do not control active intra-abdominal hemorrhage, and observation is unsafe after rupture."
            },
            {
              "id": "C",
              "text": "Option D: Perform ultrasound-guided percutaneous aspiration of the subcapsular collection is inappropriate because percutaneous aspiration can release tamponade and worsen bleeding; ruptured hematoma requires vascular or operative control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give magnesium sulfate alone and continue pregnancy until 37 weeks is inappropriate because magnesium prevents eclamptic seizures but neither treats hemorrhagic shock nor justifies prolonging this pregnancy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform ultrasound-guided percutaneous aspiration of the subcapsular collection is inappropriate because percutaneous aspiration can release tamponade and worsen bleeding; ruptured hematoma requires vascular or operative control."
            },
            {
              "id": "B",
              "text": "Option B: Administer dexamethasone and repeat hepatic imaging in 12 hours is inappropriate because corticosteroids do not control active intra-abdominal hemorrhage, and observation is unsafe after rupture."
            },
            {
              "id": "C",
              "text": "Option C: Give magnesium sulfate alone and continue pregnancy until 37 weeks is inappropriate because magnesium prevents eclamptic seizures but neither treats hemorrhagic shock nor justifies prolonging this pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform ultrasound-guided percutaneous aspiration of the subcapsular collection is inappropriate because percutaneous aspiration can release tamponade and worsen bleeding; ruptured hematoma requires vascular or operative control."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay intervention until the platelet count exceeds 100,000/mm\u00B3 after transfusion is inappropriate because thrombocytopenia is corrected during massive transfusion, but waiting for an arbitrary platelet threshold would dangerously delay source control."
            },
            {
              "id": "B",
              "text": "Option B: Administer dexamethasone and repeat hepatic imaging in 12 hours is inappropriate because corticosteroids do not control active intra-abdominal hemorrhage, and observation is unsafe after rupture."
            },
            {
              "id": "C",
              "text": "Option C: Give magnesium sulfate alone and continue pregnancy until 37 weeks is inappropriate because magnesium prevents eclamptic seizures but neither treats hemorrhagic shock nor justifies prolonging this pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay intervention until the platelet count exceeds 100,000/mm\u00B3 after transfusion is inappropriate because thrombocytopenia is corrected during massive transfusion, but waiting for an arbitrary platelet threshold would dangerously delay source control."
        }
      }
    },
    {
      "externalId": "d5-expansion-ophthalmology-acute-retinal-necrosis-combination-antiviral-001",
      "expectedHashes": {
        "ranaze_step3_uat": "3d07f039ce81c4112af0a3398c3b5da319efdc1eb6abe99539d6e960120d7608",
        "ranaze_step3_prd": "3d07f039ce81c4112af0a3398c3b5da319efdc1eb6abe99539d6e960120d7608"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin systemic corticosteroids alone immediately is inappropriate because steroid monotherapy accelerates uncontrolled herpetic infection; steroids are delayed until antiviral therapy is established."
            },
            {
              "id": "B",
              "text": "Option C: Give intravitreal bevacizumab without systemic antiviral therapy is inappropriate because anti-VEGF therapy does not treat viral retinal necrosis, and local therapy alone leaves the fellow eye unprotected."
            },
            {
              "id": "C",
              "text": "Option D: Perform prophylactic vitrectomy and scleral buckling before antiviral therapy is inappropriate because surgery treats retinal-detachment complications; it does not replace immediate antiviral control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin systemic corticosteroids alone immediately is inappropriate because steroid monotherapy accelerates uncontrolled herpetic infection; steroids are delayed until antiviral therapy is established."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give intravitreal bevacizumab without systemic antiviral therapy is inappropriate because anti-VEGF therapy does not treat viral retinal necrosis, and local therapy alone leaves the fellow eye unprotected."
            },
            {
              "id": "B",
              "text": "Option B: Begin systemic corticosteroids alone immediately is inappropriate because steroid monotherapy accelerates uncontrolled herpetic infection; steroids are delayed until antiviral therapy is established."
            },
            {
              "id": "C",
              "text": "Option D: Perform prophylactic vitrectomy and scleral buckling before antiviral therapy is inappropriate because surgery treats retinal-detachment complications; it does not replace immediate antiviral control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give intravitreal bevacizumab without systemic antiviral therapy is inappropriate because anti-VEGF therapy does not treat viral retinal necrosis, and local therapy alone leaves the fellow eye unprotected."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform prophylactic vitrectomy and scleral buckling before antiviral therapy is inappropriate because surgery treats retinal-detachment complications; it does not replace immediate antiviral control."
            },
            {
              "id": "B",
              "text": "Option B: Begin systemic corticosteroids alone immediately is inappropriate because steroid monotherapy accelerates uncontrolled herpetic infection; steroids are delayed until antiviral therapy is established."
            },
            {
              "id": "C",
              "text": "Option C: Give intravitreal bevacizumab without systemic antiviral therapy is inappropriate because anti-VEGF therapy does not treat viral retinal necrosis, and local therapy alone leaves the fellow eye unprotected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform prophylactic vitrectomy and scleral buckling before antiviral therapy is inappropriate because surgery treats retinal-detachment complications; it does not replace immediate antiviral control."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe until the fellow eye becomes involved to confirm the diagnosis is inappropriate because aRN progresses rapidly and can become bilateral; observation risks irreversible blindness."
            },
            {
              "id": "B",
              "text": "Option B: Begin systemic corticosteroids alone immediately is inappropriate because steroid monotherapy accelerates uncontrolled herpetic infection; steroids are delayed until antiviral therapy is established."
            },
            {
              "id": "C",
              "text": "Option C: Give intravitreal bevacizumab without systemic antiviral therapy is inappropriate because anti-VEGF therapy does not treat viral retinal necrosis, and local therapy alone leaves the fellow eye unprotected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe until the fellow eye becomes involved to confirm the diagnosis is inappropriate because aRN progresses rapidly and can become bilateral; observation risks irreversible blindness."
        }
      }
    },
    {
      "externalId": "d5-expansion-ophthalmology-alkali-burn-irrigation-sequence-001",
      "expectedHashes": {
        "ranaze_step3_uat": "c110b35276ec51b862a9573d539abcdbfe0ea63eeb9acda8c2bb37afee9dd2ff",
        "ranaze_step3_prd": "c110b35276ec51b862a9573d539abcdbfe0ea63eeb9acda8c2bb37afee9dd2ff"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform visual acuity, slit-lamp examination, and tonometry before irrigation is inappropriate because baseline acuity is useful only if it causes no delay; full examination and tonometry follow irrigation."
            },
            {
              "id": "B",
              "text": "Option C: Neutralize the alkali with a dilute acidic solution is inappropriate because chemical neutralization can generate heat and additional injury; use copious nontoxic irrigation instead."
            },
            {
              "id": "C",
              "text": "Option D: Instill topical corticosteroids first to reduce inflammation, then irrigate is inappropriate because steroids may be used under ophthalmic guidance after decontamination, but they must not delay irrigation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform visual acuity, slit-lamp examination, and tonometry before irrigation is inappropriate because baseline acuity is useful only if it causes no delay; full examination and tonometry follow irrigation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neutralize the alkali with a dilute acidic solution is inappropriate because chemical neutralization can generate heat and additional injury; use copious nontoxic irrigation instead."
            },
            {
              "id": "B",
              "text": "Option B: Perform visual acuity, slit-lamp examination, and tonometry before irrigation is inappropriate because baseline acuity is useful only if it causes no delay; full examination and tonometry follow irrigation."
            },
            {
              "id": "C",
              "text": "Option D: Instill topical corticosteroids first to reduce inflammation, then irrigate is inappropriate because steroids may be used under ophthalmic guidance after decontamination, but they must not delay irrigation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neutralize the alkali with a dilute acidic solution is inappropriate because chemical neutralization can generate heat and additional injury; use copious nontoxic irrigation instead."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Instill topical corticosteroids first to reduce inflammation, then irrigate is inappropriate because steroids may be used under ophthalmic guidance after decontamination, but they must not delay irrigation."
            },
            {
              "id": "B",
              "text": "Option B: Perform visual acuity, slit-lamp examination, and tonometry before irrigation is inappropriate because baseline acuity is useful only if it causes no delay; full examination and tonometry follow irrigation."
            },
            {
              "id": "C",
              "text": "Option C: Neutralize the alkali with a dilute acidic solution is inappropriate because chemical neutralization can generate heat and additional injury; use copious nontoxic irrigation instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Instill topical corticosteroids first to reduce inflammation, then irrigate is inappropriate because steroids may be used under ophthalmic guidance after decontamination, but they must not delay irrigation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patch both eyes and wait for ophthalmology to perform controlled irrigation is inappropriate because patching traps the chemical and delays the single most important intervention."
            },
            {
              "id": "B",
              "text": "Option B: Perform visual acuity, slit-lamp examination, and tonometry before irrigation is inappropriate because baseline acuity is useful only if it causes no delay; full examination and tonometry follow irrigation."
            },
            {
              "id": "C",
              "text": "Option C: Neutralize the alkali with a dilute acidic solution is inappropriate because chemical neutralization can generate heat and additional injury; use copious nontoxic irrigation instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patch both eyes and wait for ophthalmology to perform controlled irrigation is inappropriate because patching traps the chemical and delays the single most important intervention."
        }
      }
    },
    {
      "externalId": "d5-expansion-ophthalmology-orbital-compartment-decompression-001",
      "expectedHashes": {
        "ranaze_step3_uat": "86b5774fa8b1648a878f3309a0ef535a7d996113cafff778f7f37b4ffac5ae00",
        "ranaze_step3_prd": "86b5774fa8b1648a878f3309a0ef535a7d996113cafff778f7f37b4ffac5ae00"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain emergent CT of the orbits before treating is inappropriate because oCS is a clinical diagnosis; CT delays reperfusion of the optic nerve and retina."
            },
            {
              "id": "B",
              "text": "Option C: Give intravenous acetazolamide and mannitol and await ophthalmology is inappropriate because acetazolamide and mannitol are adjuncts and cannot replace urgent decompression."
            },
            {
              "id": "C",
              "text": "Option D: Reverse apixaban and reassess vision after coagulation normalizes is inappropriate because reversal addresses ongoing bleeding but is too slow to relieve current orbital pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain emergent CT of the orbits before treating is inappropriate because oCS is a clinical diagnosis; CT delays reperfusion of the optic nerve and retina."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give intravenous acetazolamide and mannitol and await ophthalmology is inappropriate because acetazolamide and mannitol are adjuncts and cannot replace urgent decompression."
            },
            {
              "id": "B",
              "text": "Option B: Obtain emergent CT of the orbits before treating is inappropriate because oCS is a clinical diagnosis; CT delays reperfusion of the optic nerve and retina."
            },
            {
              "id": "C",
              "text": "Option D: Reverse apixaban and reassess vision after coagulation normalizes is inappropriate because reversal addresses ongoing bleeding but is too slow to relieve current orbital pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give intravenous acetazolamide and mannitol and await ophthalmology is inappropriate because acetazolamide and mannitol are adjuncts and cannot replace urgent decompression."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reverse apixaban and reassess vision after coagulation normalizes is inappropriate because reversal addresses ongoing bleeding but is too slow to relieve current orbital pressure."
            },
            {
              "id": "B",
              "text": "Option B: Obtain emergent CT of the orbits before treating is inappropriate because oCS is a clinical diagnosis; CT delays reperfusion of the optic nerve and retina."
            },
            {
              "id": "C",
              "text": "Option C: Give intravenous acetazolamide and mannitol and await ophthalmology is inappropriate because acetazolamide and mannitol are adjuncts and cannot replace urgent decompression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reverse apixaban and reassess vision after coagulation normalizes is inappropriate because reversal addresses ongoing bleeding but is too slow to relieve current orbital pressure."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform needle aspiration through the upper eyelid without cantholysis is inappropriate because blind needle aspiration is unreliable and risks globe injury; canthotomy with cantholysis is the standard bedside decompression."
            },
            {
              "id": "B",
              "text": "Option B: Obtain emergent CT of the orbits before treating is inappropriate because oCS is a clinical diagnosis; CT delays reperfusion of the optic nerve and retina."
            },
            {
              "id": "C",
              "text": "Option C: Give intravenous acetazolamide and mannitol and await ophthalmology is inappropriate because acetazolamide and mannitol are adjuncts and cannot replace urgent decompression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform needle aspiration through the upper eyelid without cantholysis is inappropriate because blind needle aspiration is unreliable and risks globe injury; canthotomy with cantholysis is the standard bedside decompression."
        }
      }
    },
    {
      "externalId": "d5-expansion-pediatrics-cdh-delivery-stabilization-001",
      "expectedHashes": {
        "ranaze_step3_uat": "4aba5e534ad07503011500efebcf24a0cd21e1c1f559b1f6d14abe41036bbee5",
        "ranaze_step3_prd": "4aba5e534ad07503011500efebcf24a0cd21e1c1f559b1f6d14abe41036bbee5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vigorous bag-mask ventilation followed by immediate operative closure of the diaphragm is inappropriate because mask ventilation worsens bowel distention, and repair before stabilization increases risk."
            },
            {
              "id": "B",
              "text": "Option C: Needle decompression of the left chest followed by chest-tube placement is inappropriate because the thoracic lucencies are bowel, not free pleural air; invasive decompression can injure viscera."
            },
            {
              "id": "C",
              "text": "Option D: High-frequency chest compressions and oral feeding to reduce bowel distention is inappropriate because chest compressions are not indicated at a heart rate of 150/min, and oral feeding worsens distention and aspiration risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vigorous bag-mask ventilation followed by immediate operative closure of the diaphragm is inappropriate because mask ventilation worsens bowel distention, and repair before stabilization increases risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Needle decompression of the left chest followed by chest-tube placement is inappropriate because the thoracic lucencies are bowel, not free pleural air; invasive decompression can injure viscera."
            },
            {
              "id": "B",
              "text": "Option B: Vigorous bag-mask ventilation followed by immediate operative closure of the diaphragm is inappropriate because mask ventilation worsens bowel distention, and repair before stabilization increases risk."
            },
            {
              "id": "C",
              "text": "Option D: High-frequency chest compressions and oral feeding to reduce bowel distention is inappropriate because chest compressions are not indicated at a heart rate of 150/min, and oral feeding worsens distention and aspiration risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Needle decompression of the left chest followed by chest-tube placement is inappropriate because the thoracic lucencies are bowel, not free pleural air; invasive decompression can injure viscera."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-frequency chest compressions and oral feeding to reduce bowel distention is inappropriate because chest compressions are not indicated at a heart rate of 150/min, and oral feeding worsens distention and aspiration risk."
            },
            {
              "id": "B",
              "text": "Option B: Vigorous bag-mask ventilation followed by immediate operative closure of the diaphragm is inappropriate because mask ventilation worsens bowel distention, and repair before stabilization increases risk."
            },
            {
              "id": "C",
              "text": "Option C: Needle decompression of the left chest followed by chest-tube placement is inappropriate because the thoracic lucencies are bowel, not free pleural air; invasive decompression can injure viscera."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-frequency chest compressions and oral feeding to reduce bowel distention is inappropriate because chest compressions are not indicated at a heart rate of 150/min, and oral feeding worsens distention and aspiration risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate transport to the operating room without respiratory stabilization is inappropriate because cDH is stabilized medically before operative repair."
            },
            {
              "id": "B",
              "text": "Option B: Vigorous bag-mask ventilation followed by immediate operative closure of the diaphragm is inappropriate because mask ventilation worsens bowel distention, and repair before stabilization increases risk."
            },
            {
              "id": "C",
              "text": "Option C: Needle decompression of the left chest followed by chest-tube placement is inappropriate because the thoracic lucencies are bowel, not free pleural air; invasive decompression can injure viscera."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate transport to the operating room without respiratory stabilization is inappropriate because cDH is stabilized medically before operative repair."
        }
      }
    },
    {
      "externalId": "d5-expansion-pediatrics-fnait-intracranial-bleeding-001",
      "expectedHashes": {
        "ranaze_step3_uat": "0cfe4c4f194f7cb6ca37accd92b9e09a4bdf33c7232cb9b3685c048df46a3aae",
        "ranaze_step3_prd": "0cfe4c4f194f7cb6ca37accd92b9e09a4bdf33c7232cb9b3685c048df46a3aae"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for HPA-compatible platelets because incompatible platelets provide no hemostatic benefit is inappropriate because waiting prolongs critical thrombocytopenia; unmatched platelets can still provide a transient protective increment."
            },
            {
              "id": "B",
              "text": "Option C: Give intravenous immune globulin alone and recheck the platelet count tomorrow is inappropriate because iVIG does not act rapidly enough and current evidence does not support it as sole rescue for active major bleeding."
            },
            {
              "id": "C",
              "text": "Option D: Treat the mother with glucocorticoids and continue breastfeeding is inappropriate because postnatal maternal glucocorticoids do not correct the newborn\u0027s immediate thrombocytopenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for HPA-compatible platelets because incompatible platelets provide no hemostatic benefit is inappropriate because waiting prolongs critical thrombocytopenia; unmatched platelets can still provide a transient protective increment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give intravenous immune globulin alone and recheck the platelet count tomorrow is inappropriate because iVIG does not act rapidly enough and current evidence does not support it as sole rescue for active major bleeding."
            },
            {
              "id": "B",
              "text": "Option B: Wait for HPA-compatible platelets because incompatible platelets provide no hemostatic benefit is inappropriate because waiting prolongs critical thrombocytopenia; unmatched platelets can still provide a transient protective increment."
            },
            {
              "id": "C",
              "text": "Option D: Treat the mother with glucocorticoids and continue breastfeeding is inappropriate because postnatal maternal glucocorticoids do not correct the newborn\u0027s immediate thrombocytopenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give intravenous immune globulin alone and recheck the platelet count tomorrow is inappropriate because iVIG does not act rapidly enough and current evidence does not support it as sole rescue for active major bleeding."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat the mother with glucocorticoids and continue breastfeeding is inappropriate because postnatal maternal glucocorticoids do not correct the newborn\u0027s immediate thrombocytopenia."
            },
            {
              "id": "B",
              "text": "Option B: Wait for HPA-compatible platelets because incompatible platelets provide no hemostatic benefit is inappropriate because waiting prolongs critical thrombocytopenia; unmatched platelets can still provide a transient protective increment."
            },
            {
              "id": "C",
              "text": "Option C: Give intravenous immune globulin alone and recheck the platelet count tomorrow is inappropriate because iVIG does not act rapidly enough and current evidence does not support it as sole rescue for active major bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat the mother with glucocorticoids and continue breastfeeding is inappropriate because postnatal maternal glucocorticoids do not correct the newborn\u0027s immediate thrombocytopenia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform exchange transfusion with packed red blood cells is inappropriate because red-cell exchange does not supply the platelets needed for hemostasis."
            },
            {
              "id": "B",
              "text": "Option B: Wait for HPA-compatible platelets because incompatible platelets provide no hemostatic benefit is inappropriate because waiting prolongs critical thrombocytopenia; unmatched platelets can still provide a transient protective increment."
            },
            {
              "id": "C",
              "text": "Option C: Give intravenous immune globulin alone and recheck the platelet count tomorrow is inappropriate because iVIG does not act rapidly enough and current evidence does not support it as sole rescue for active major bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform exchange transfusion with packed red blood cells is inappropriate because red-cell exchange does not supply the platelets needed for hemostasis."
        }
      }
    },
    {
      "externalId": "d5-expansion-pediatrics-hie-therapeutic-hypothermia-001",
      "expectedHashes": {
        "ranaze_step3_uat": "d2864af817188f9fff2b1d2d5f897ccd47201fff83d23309d4c8d47ae76716af",
        "ranaze_step3_prd": "d2864af817188f9fff2b1d2d5f897ccd47201fff83d23309d4c8d47ae76716af"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maintain normothermia until brain MRI confirms hypoxic injury is inappropriate because mRI confirmation comes later and would squander the therapeutic window."
            },
            {
              "id": "B",
              "text": "Option C: Cool to 32\u00B0C for 120 hours to maximize neuroprotection is inappropriate because the evidence-based regimen is moderate cooling for 72 hours; deeper and longer cooling is not superior."
            },
            {
              "id": "C",
              "text": "Option D: Wait until 12 hours of age to determine whether encephalopathy persists is inappropriate because waiting beyond 6 hours reduces the evidence-supported neuroprotective opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maintain normothermia until brain MRI confirms hypoxic injury is inappropriate because mRI confirmation comes later and would squander the therapeutic window."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cool to 32\u00B0C for 120 hours to maximize neuroprotection is inappropriate because the evidence-based regimen is moderate cooling for 72 hours; deeper and longer cooling is not superior."
            },
            {
              "id": "B",
              "text": "Option B: Maintain normothermia until brain MRI confirms hypoxic injury is inappropriate because mRI confirmation comes later and would squander the therapeutic window."
            },
            {
              "id": "C",
              "text": "Option D: Wait until 12 hours of age to determine whether encephalopathy persists is inappropriate because waiting beyond 6 hours reduces the evidence-supported neuroprotective opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cool to 32\u00B0C for 120 hours to maximize neuroprotection is inappropriate because the evidence-based regimen is moderate cooling for 72 hours; deeper and longer cooling is not superior."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait until 12 hours of age to determine whether encephalopathy persists is inappropriate because waiting beyond 6 hours reduces the evidence-supported neuroprotective opportunity."
            },
            {
              "id": "B",
              "text": "Option B: Maintain normothermia until brain MRI confirms hypoxic injury is inappropriate because mRI confirmation comes later and would squander the therapeutic window."
            },
            {
              "id": "C",
              "text": "Option C: Cool to 32\u00B0C for 120 hours to maximize neuroprotection is inappropriate because the evidence-based regimen is moderate cooling for 72 hours; deeper and longer cooling is not superior."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait until 12 hours of age to determine whether encephalopathy persists is inappropriate because waiting beyond 6 hours reduces the evidence-supported neuroprotective opportunity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer high-dose dexamethasone instead of cooling is inappropriate because glucocorticoids do not replace therapeutic hypothermia for HIE."
            },
            {
              "id": "B",
              "text": "Option B: Maintain normothermia until brain MRI confirms hypoxic injury is inappropriate because mRI confirmation comes later and would squander the therapeutic window."
            },
            {
              "id": "C",
              "text": "Option C: Cool to 32\u00B0C for 120 hours to maximize neuroprotection is inappropriate because the evidence-based regimen is moderate cooling for 72 hours; deeper and longer cooling is not superior."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer high-dose dexamethasone instead of cooling is inappropriate because glucocorticoids do not replace therapeutic hypothermia for HIE."
        }
      }
    },
    {
      "externalId": "d5-expansion-preventive-occupational-triple-virus-exposure-001",
      "expectedHashes": {
        "ranaze_step3_uat": "8fa41f32ae7c0a1add48dff925303cdbc06e5742fe2fdad5a359ee2d978da62d",
        "ranaze_step3_prd": "8fa41f32ae7c0a1add48dff925303cdbc06e5742fe2fdad5a359ee2d978da62d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for an HIV nucleic acid test, give hepatitis B vaccine alone, and start direct-acting antivirals for HCV prophylaxis is inappropriate because hIV PEP should not await NAT; the HBV response requires HBIG plus revaccination, and HCV antivirals are not used prophylactically."
            },
            {
              "id": "B",
              "text": "Option C: Start 2-drug HIV PEP, give HBIG alone, and administer hepatitis C immune globulin is inappropriate because recommended HIV PEP uses three drugs; HBV revaccination is also needed, and hepatitis C immune globulin is ineffective."
            },
            {
              "id": "C",
              "text": "Option D: Give no HIV or HBV prophylaxis because she was wearing gloves and completed hepatitis B vaccination is inappropriate because a deep hollow-bore injury remains high risk, and her anti-HBs level does not document protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for an HIV nucleic acid test, give hepatitis B vaccine alone, and start direct-acting antivirals for HCV prophylaxis is inappropriate because hIV PEP should not await NAT; the HBV response requires HBIG plus revaccination, and HCV antivirals are not used prophylactically."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start 2-drug HIV PEP, give HBIG alone, and administer hepatitis C immune globulin is inappropriate because recommended HIV PEP uses three drugs; HBV revaccination is also needed, and hepatitis C immune globulin is ineffective."
            },
            {
              "id": "B",
              "text": "Option B: Wait for an HIV nucleic acid test, give hepatitis B vaccine alone, and start direct-acting antivirals for HCV prophylaxis is inappropriate because hIV PEP should not await NAT; the HBV response requires HBIG plus revaccination, and HCV antivirals are not used prophylactically."
            },
            {
              "id": "C",
              "text": "Option D: Give no HIV or HBV prophylaxis because she was wearing gloves and completed hepatitis B vaccination is inappropriate because a deep hollow-bore injury remains high risk, and her anti-HBs level does not document protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start 2-drug HIV PEP, give HBIG alone, and administer hepatitis C immune globulin is inappropriate because recommended HIV PEP uses three drugs; HBV revaccination is also needed, and hepatitis C immune globulin is ineffective."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give no HIV or HBV prophylaxis because she was wearing gloves and completed hepatitis B vaccination is inappropriate because a deep hollow-bore injury remains high risk, and her anti-HBs level does not document protection."
            },
            {
              "id": "B",
              "text": "Option B: Wait for an HIV nucleic acid test, give hepatitis B vaccine alone, and start direct-acting antivirals for HCV prophylaxis is inappropriate because hIV PEP should not await NAT; the HBV response requires HBIG plus revaccination, and HCV antivirals are not used prophylactically."
            },
            {
              "id": "C",
              "text": "Option C: Start 2-drug HIV PEP, give HBIG alone, and administer hepatitis C immune globulin is inappropriate because recommended HIV PEP uses three drugs; HBV revaccination is also needed, and hepatitis C immune globulin is ineffective."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give no HIV or HBV prophylaxis because she was wearing gloves and completed hepatitis B vaccination is inappropriate because a deep hollow-bore injury remains high risk, and her anti-HBs level does not document protection."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start lifelong HIV therapy, repeat hepatitis B vaccine in 6 months, and defer HCV testing until symptoms occur is inappropriate because pEP is 28 days rather than lifelong therapy, HBV prophylaxis is immediate, and asymptomatic HCV infection requires scheduled testing."
            },
            {
              "id": "B",
              "text": "Option B: Wait for an HIV nucleic acid test, give hepatitis B vaccine alone, and start direct-acting antivirals for HCV prophylaxis is inappropriate because hIV PEP should not await NAT; the HBV response requires HBIG plus revaccination, and HCV antivirals are not used prophylactically."
            },
            {
              "id": "C",
              "text": "Option C: Start 2-drug HIV PEP, give HBIG alone, and administer hepatitis C immune globulin is inappropriate because recommended HIV PEP uses three drugs; HBV revaccination is also needed, and hepatitis C immune globulin is ineffective."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start lifelong HIV therapy, repeat hepatitis B vaccine in 6 months, and defer HCV testing until symptoms occur is inappropriate because pEP is 28 days rather than lifelong therapy, HBV prophylaxis is immediate, and asymptomatic HCV infection requires scheduled testing."
        }
      }
    },
    {
      "externalId": "d5-expansion-preventive-postsplenectomy-vaccine-series-001",
      "expectedHashes": {
        "ranaze_step3_uat": "571ea1b66d66015960f66bb24d106b7baf4eaecba01a8afab17f692b0a954e08",
        "ranaze_step3_prd": "571ea1b66d66015960f66bb24d106b7baf4eaecba01a8afab17f692b0a954e08"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give PPSV23 alone now; meningococcal and Hib vaccination are unnecessary in adults is inappropriate because pPSV23 alone omits conjugate pneumococcal protection and the necessary Hib and meningococcal vaccines."
            },
            {
              "id": "B",
              "text": "Option C: Give MMR, varicella, and live attenuated influenza vaccines only is inappropriate because these live vaccines do not target the encapsulated organisms responsible for overwhelming postsplenectomy infection."
            },
            {
              "id": "C",
              "text": "Option D: Delay all vaccines until 1 year after surgery because responses are ineffective after emergency splenectomy is inappropriate because vaccines should be given before elective surgery when possible or once stable after emergency surgery\u2014not delayed for a year."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give PPSV23 alone now; meningococcal and Hib vaccination are unnecessary in adults is inappropriate because pPSV23 alone omits conjugate pneumococcal protection and the necessary Hib and meningococcal vaccines."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give MMR, varicella, and live attenuated influenza vaccines only is inappropriate because these live vaccines do not target the encapsulated organisms responsible for overwhelming postsplenectomy infection."
            },
            {
              "id": "B",
              "text": "Option B: Give PPSV23 alone now; meningococcal and Hib vaccination are unnecessary in adults is inappropriate because pPSV23 alone omits conjugate pneumococcal protection and the necessary Hib and meningococcal vaccines."
            },
            {
              "id": "C",
              "text": "Option D: Delay all vaccines until 1 year after surgery because responses are ineffective after emergency splenectomy is inappropriate because vaccines should be given before elective surgery when possible or once stable after emergency surgery\u2014not delayed for a year."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give MMR, varicella, and live attenuated influenza vaccines only is inappropriate because these live vaccines do not target the encapsulated organisms responsible for overwhelming postsplenectomy infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay all vaccines until 1 year after surgery because responses are ineffective after emergency splenectomy is inappropriate because vaccines should be given before elective surgery when possible or once stable after emergency surgery\u2014not delayed for a year."
            },
            {
              "id": "B",
              "text": "Option B: Give PPSV23 alone now; meningococcal and Hib vaccination are unnecessary in adults is inappropriate because pPSV23 alone omits conjugate pneumococcal protection and the necessary Hib and meningococcal vaccines."
            },
            {
              "id": "C",
              "text": "Option C: Give MMR, varicella, and live attenuated influenza vaccines only is inappropriate because these live vaccines do not target the encapsulated organisms responsible for overwhelming postsplenectomy infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay all vaccines until 1 year after surgery because responses are ineffective after emergency splenectomy is inappropriate because vaccines should be given before elective surgery when possible or once stable after emergency surgery\u2014not delayed for a year."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give one MenACWY dose only; it covers serogroup B and requires no booster is inappropriate because menACWY excludes serogroup B and requires a 2-dose primary series plus 5-year boosters in asplenia."
            },
            {
              "id": "B",
              "text": "Option B: Give PPSV23 alone now; meningococcal and Hib vaccination are unnecessary in adults is inappropriate because pPSV23 alone omits conjugate pneumococcal protection and the necessary Hib and meningococcal vaccines."
            },
            {
              "id": "C",
              "text": "Option C: Give MMR, varicella, and live attenuated influenza vaccines only is inappropriate because these live vaccines do not target the encapsulated organisms responsible for overwhelming postsplenectomy infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give one MenACWY dose only; it covers serogroup B and requires no booster is inappropriate because menACWY excludes serogroup B and requires a 2-dose primary series plus 5-year boosters in asplenia."
        }
      }
    },
    {
      "externalId": "d5-expansion-preventive-pregnant-measles-exposure-001",
      "expectedHashes": {
        "ranaze_step3_uat": "53033f81d60181097b4a05cedfc38a424bf3b139aa750aa8a326b1a4d7d161e8",
        "ranaze_step3_prd": "53033f81d60181097b4a05cedfc38a424bf3b139aa750aa8a326b1a4d7d161e8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer MMR vaccine now because exposure occurred less than 6 days ago is inappropriate because mMR is a live vaccine and is contraindicated during pregnancy regardless of exposure timing."
            },
            {
              "id": "B",
              "text": "Option C: Give intramuscular immune globulin and MMR vaccine simultaneously is inappropriate because giving MMR during pregnancy is contraindicated, and simultaneous immune globulin can also interfere with vaccine response."
            },
            {
              "id": "C",
              "text": "Option D: Wait for fever or rash, then begin oral ribavirin is inappropriate because postexposure prophylaxis must precede symptoms; ribavirin is not routine measles PEP."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer MMR vaccine now because exposure occurred less than 6 days ago is inappropriate because mMR is a live vaccine and is contraindicated during pregnancy regardless of exposure timing."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give intramuscular immune globulin and MMR vaccine simultaneously is inappropriate because giving MMR during pregnancy is contraindicated, and simultaneous immune globulin can also interfere with vaccine response."
            },
            {
              "id": "B",
              "text": "Option B: Administer MMR vaccine now because exposure occurred less than 6 days ago is inappropriate because mMR is a live vaccine and is contraindicated during pregnancy regardless of exposure timing."
            },
            {
              "id": "C",
              "text": "Option D: Wait for fever or rash, then begin oral ribavirin is inappropriate because postexposure prophylaxis must precede symptoms; ribavirin is not routine measles PEP."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give intramuscular immune globulin and MMR vaccine simultaneously is inappropriate because giving MMR during pregnancy is contraindicated, and simultaneous immune globulin can also interfere with vaccine response."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for fever or rash, then begin oral ribavirin is inappropriate because postexposure prophylaxis must precede symptoms; ribavirin is not routine measles PEP."
            },
            {
              "id": "B",
              "text": "Option B: Administer MMR vaccine now because exposure occurred less than 6 days ago is inappropriate because mMR is a live vaccine and is contraindicated during pregnancy regardless of exposure timing."
            },
            {
              "id": "C",
              "text": "Option C: Give intramuscular immune globulin and MMR vaccine simultaneously is inappropriate because giving MMR during pregnancy is contraindicated, and simultaneous immune globulin can also interfere with vaccine response."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for fever or rash, then begin oral ribavirin is inappropriate because postexposure prophylaxis must precede symptoms; ribavirin is not routine measles PEP."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide no prophylaxis because maternal measles does not increase pregnancy risk is inappropriate because pregnancy increases the risk of severe maternal and fetal complications from measles."
            },
            {
              "id": "B",
              "text": "Option B: Administer MMR vaccine now because exposure occurred less than 6 days ago is inappropriate because mMR is a live vaccine and is contraindicated during pregnancy regardless of exposure timing."
            },
            {
              "id": "C",
              "text": "Option C: Give intramuscular immune globulin and MMR vaccine simultaneously is inappropriate because giving MMR during pregnancy is contraindicated, and simultaneous immune globulin can also interfere with vaccine response."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide no prophylaxis because maternal measles does not increase pregnancy risk is inappropriate because pregnancy increases the risk of severe maternal and fetal complications from measles."
        }
      }
    },
    {
      "externalId": "d5-expansion-reproductive-adnexal-torsion-preservation-001",
      "expectedHashes": {
        "ranaze_step3_uat": "71bf1d9422e9ea5185ee204c8c375270584b0dbc47803dc7c93d45d2f62e44d9",
        "ranaze_step3_prd": "71bf1d9422e9ea5185ee204c8c375270584b0dbc47803dc7c93d45d2f62e44d9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform right salpingo-oophorectomy because the color proves irreversible necrosis is inappropriate because blue-black appearance alone is not proof of necrosis and should not trigger oophorectomy."
            },
            {
              "id": "B",
              "text": "Option C: Retwist the pedicle to prevent systemic embolization is inappropriate because no evidence supports retorsion to prevent embolism; doing so perpetuates ischemia."
            },
            {
              "id": "C",
              "text": "Option D: Close the incisions and repeat Doppler ultrasonography in 24 hours before intervening is inappropriate because the diagnosis is confirmed surgically and has already been treated by detorsion; delaying leaves the ovary at risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform right salpingo-oophorectomy because the color proves irreversible necrosis is inappropriate because blue-black appearance alone is not proof of necrosis and should not trigger oophorectomy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Retwist the pedicle to prevent systemic embolization is inappropriate because no evidence supports retorsion to prevent embolism; doing so perpetuates ischemia."
            },
            {
              "id": "B",
              "text": "Option B: Perform right salpingo-oophorectomy because the color proves irreversible necrosis is inappropriate because blue-black appearance alone is not proof of necrosis and should not trigger oophorectomy."
            },
            {
              "id": "C",
              "text": "Option D: Close the incisions and repeat Doppler ultrasonography in 24 hours before intervening is inappropriate because the diagnosis is confirmed surgically and has already been treated by detorsion; delaying leaves the ovary at risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Retwist the pedicle to prevent systemic embolization is inappropriate because no evidence supports retorsion to prevent embolism; doing so perpetuates ischemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Close the incisions and repeat Doppler ultrasonography in 24 hours before intervening is inappropriate because the diagnosis is confirmed surgically and has already been treated by detorsion; delaying leaves the ovary at risk."
            },
            {
              "id": "B",
              "text": "Option B: Perform right salpingo-oophorectomy because the color proves irreversible necrosis is inappropriate because blue-black appearance alone is not proof of necrosis and should not trigger oophorectomy."
            },
            {
              "id": "C",
              "text": "Option C: Retwist the pedicle to prevent systemic embolization is inappropriate because no evidence supports retorsion to prevent embolism; doing so perpetuates ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Close the incisions and repeat Doppler ultrasonography in 24 hours before intervening is inappropriate because the diagnosis is confirmed surgically and has already been treated by detorsion; delaying leaves the ovary at risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform bilateral oophoropexy routinely to prevent recurrence is inappropriate because routine fixation after a first torsion is controversial and unsupported; it is mainly considered for recurrence or an absent contralateral ovary."
            },
            {
              "id": "B",
              "text": "Option B: Perform right salpingo-oophorectomy because the color proves irreversible necrosis is inappropriate because blue-black appearance alone is not proof of necrosis and should not trigger oophorectomy."
            },
            {
              "id": "C",
              "text": "Option C: Retwist the pedicle to prevent systemic embolization is inappropriate because no evidence supports retorsion to prevent embolism; doing so perpetuates ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform bilateral oophoropexy routinely to prevent recurrence is inappropriate because routine fixation after a first torsion is controversial and unsupported; it is mainly considered for recurrence or an absent contralateral ovary."
        }
      }
    },
    {
      "externalId": "d5-expansion-reproductive-penile-fracture-urethral-injury-001",
      "expectedHashes": {
        "ranaze_step3_uat": "f4fdd94d98ca7c3cd49fadac8de6421693bd2818c35924bce1b175a3031059e1",
        "ranaze_step3_prd": "f4fdd94d98ca7c3cd49fadac8de6421693bd2818c35924bce1b175a3031059e1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place a transurethral Foley catheter and discharge with compression and analgesia is inappropriate because blind catheterization may extend urethral injury, and conservative fracture management has worse functional outcomes."
            },
            {
              "id": "B",
              "text": "Option C: Obtain magnetic resonance imaging before deciding whether exploration is necessary is inappropriate because the clinical diagnosis is clear; MRI would delay definitive repair."
            },
            {
              "id": "C",
              "text": "Option D: Apply a penile tourniquet and aspirate the corporal hematoma is inappropriate because aspiration does not close the tunical tear or evaluate/repair the urethra."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place a transurethral Foley catheter and discharge with compression and analgesia is inappropriate because blind catheterization may extend urethral injury, and conservative fracture management has worse functional outcomes."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain magnetic resonance imaging before deciding whether exploration is necessary is inappropriate because the clinical diagnosis is clear; MRI would delay definitive repair."
            },
            {
              "id": "B",
              "text": "Option B: Place a transurethral Foley catheter and discharge with compression and analgesia is inappropriate because blind catheterization may extend urethral injury, and conservative fracture management has worse functional outcomes."
            },
            {
              "id": "C",
              "text": "Option D: Apply a penile tourniquet and aspirate the corporal hematoma is inappropriate because aspiration does not close the tunical tear or evaluate/repair the urethra."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain magnetic resonance imaging before deciding whether exploration is necessary is inappropriate because the clinical diagnosis is clear; MRI would delay definitive repair."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply a penile tourniquet and aspirate the corporal hematoma is inappropriate because aspiration does not close the tunical tear or evaluate/repair the urethra."
            },
            {
              "id": "B",
              "text": "Option B: Place a transurethral Foley catheter and discharge with compression and analgesia is inappropriate because blind catheterization may extend urethral injury, and conservative fracture management has worse functional outcomes."
            },
            {
              "id": "C",
              "text": "Option C: Obtain magnetic resonance imaging before deciding whether exploration is necessary is inappropriate because the clinical diagnosis is clear; MRI would delay definitive repair."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply a penile tourniquet and aspirate the corporal hematoma is inappropriate because aspiration does not close the tunical tear or evaluate/repair the urethra."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay repair for 7\u201310 days until swelling resolves is inappropriate because delayed repair increases fibrosis, curvature, pain, and erectile complications."
            },
            {
              "id": "B",
              "text": "Option B: Place a transurethral Foley catheter and discharge with compression and analgesia is inappropriate because blind catheterization may extend urethral injury, and conservative fracture management has worse functional outcomes."
            },
            {
              "id": "C",
              "text": "Option C: Obtain magnetic resonance imaging before deciding whether exploration is necessary is inappropriate because the clinical diagnosis is clear; MRI would delay definitive repair."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay repair for 7\u201310 days until swelling resolves is inappropriate because delayed repair increases fibrosis, curvature, pain, and erectile complications."
        }
      }
    },
    {
      "externalId": "d5-expansion-reproductive-severe-ohss-management-001",
      "expectedHashes": {
        "ranaze_step3_uat": "b0bb15e9a59aac7eca8cbacff782ed690413b2e29623e6b5fe2881eb932ba7f1",
        "ranaze_step3_prd": "b0bb15e9a59aac7eca8cbacff782ed690413b2e29623e6b5fe2881eb932ba7f1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give intravenous furosemide and restrict fluids until the hematocrit normalizes is inappropriate because the patient is intravascularly depleted despite ascites; immediate diuresis and restriction can worsen shock and acute kidney injury."
            },
            {
              "id": "B",
              "text": "Option C: Perform immediate bilateral oophorectomy is inappropriate because oophorectomy does not reverse systemic capillary leak and sacrifices fertility unnecessarily."
            },
            {
              "id": "C",
              "text": "Option D: Administer therapeutic-dose heparin and tissue plasminogen activator is inappropriate because thromboprophylaxis is indicated, but thrombolysis and therapeutic anticoagulation require documented or strongly suspected thrombosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give intravenous furosemide and restrict fluids until the hematocrit normalizes is inappropriate because the patient is intravascularly depleted despite ascites; immediate diuresis and restriction can worsen shock and acute kidney injury."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate bilateral oophorectomy is inappropriate because oophorectomy does not reverse systemic capillary leak and sacrifices fertility unnecessarily."
            },
            {
              "id": "B",
              "text": "Option B: Give intravenous furosemide and restrict fluids until the hematocrit normalizes is inappropriate because the patient is intravascularly depleted despite ascites; immediate diuresis and restriction can worsen shock and acute kidney injury."
            },
            {
              "id": "C",
              "text": "Option D: Administer therapeutic-dose heparin and tissue plasminogen activator is inappropriate because thromboprophylaxis is indicated, but thrombolysis and therapeutic anticoagulation require documented or strongly suspected thrombosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate bilateral oophorectomy is inappropriate because oophorectomy does not reverse systemic capillary leak and sacrifices fertility unnecessarily."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer therapeutic-dose heparin and tissue plasminogen activator is inappropriate because thromboprophylaxis is indicated, but thrombolysis and therapeutic anticoagulation require documented or strongly suspected thrombosis."
            },
            {
              "id": "B",
              "text": "Option B: Give intravenous furosemide and restrict fluids until the hematocrit normalizes is inappropriate because the patient is intravascularly depleted despite ascites; immediate diuresis and restriction can worsen shock and acute kidney injury."
            },
            {
              "id": "C",
              "text": "Option C: Perform immediate bilateral oophorectomy is inappropriate because oophorectomy does not reverse systemic capillary leak and sacrifices fertility unnecessarily."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer therapeutic-dose heparin and tissue plasminogen activator is inappropriate because thromboprophylaxis is indicated, but thrombolysis and therapeutic anticoagulation require documented or strongly suspected thrombosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with oral hydration and daily weight monitoring is inappropriate because hypotension, oliguria, renal dysfunction, hemoconcentration, dyspnea, and tense ascites require inpatient care."
            },
            {
              "id": "B",
              "text": "Option B: Give intravenous furosemide and restrict fluids until the hematocrit normalizes is inappropriate because the patient is intravascularly depleted despite ascites; immediate diuresis and restriction can worsen shock and acute kidney injury."
            },
            {
              "id": "C",
              "text": "Option C: Perform immediate bilateral oophorectomy is inappropriate because oophorectomy does not reverse systemic capillary leak and sacrifices fertility unnecessarily."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with oral hydration and daily weight monitoring is inappropriate because hypotension, oliguria, renal dysfunction, hemoconcentration, dyspnea, and tense ascites require inpatient care."
        }
      }
    },
    {
      "externalId": "d5-expansion-sleep-narcolepsy-cataplexy-dual-treatment-001",
      "expectedHashes": {
        "ranaze_step3_uat": "22a3409dd335f97d2b9af26ab1ae167d4a63a1bacf82e474227072573f89bb4b",
        "ranaze_step3_prd": "22a3409dd335f97d2b9af26ab1ae167d4a63a1bacf82e474227072573f89bb4b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diphenhydramine at bedtime is inappropriate because sedating antihistamines worsen daytime somnolence and do not treat cataplexy."
            },
            {
              "id": "B",
              "text": "Option C: Melatonin alone at bedtime is inappropriate because melatonin may help sleep timing but is not established therapy for cataplexy or narcoleptic sleepiness."
            },
            {
              "id": "C",
              "text": "Option D: Bupropion only as a wake-promoting substitute is inappropriate because bupropion is not a guideline-recommended core narcolepsy treatment and does not reliably control cataplexy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diphenhydramine at bedtime is inappropriate because sedating antihistamines worsen daytime somnolence and do not treat cataplexy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Melatonin alone at bedtime is inappropriate because melatonin may help sleep timing but is not established therapy for cataplexy or narcoleptic sleepiness."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine at bedtime is inappropriate because sedating antihistamines worsen daytime somnolence and do not treat cataplexy."
            },
            {
              "id": "C",
              "text": "Option D: Bupropion only as a wake-promoting substitute is inappropriate because bupropion is not a guideline-recommended core narcolepsy treatment and does not reliably control cataplexy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Melatonin alone at bedtime is inappropriate because melatonin may help sleep timing but is not established therapy for cataplexy or narcoleptic sleepiness."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bupropion only as a wake-promoting substitute is inappropriate because bupropion is not a guideline-recommended core narcolepsy treatment and does not reliably control cataplexy."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine at bedtime is inappropriate because sedating antihistamines worsen daytime somnolence and do not treat cataplexy."
            },
            {
              "id": "C",
              "text": "Option C: Melatonin alone at bedtime is inappropriate because melatonin may help sleep timing but is not established therapy for cataplexy or narcoleptic sleepiness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bupropion only as a wake-promoting substitute is inappropriate because bupropion is not a guideline-recommended core narcolepsy treatment and does not reliably control cataplexy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Levodopa before emotionally intense activities is inappropriate because dopaminergic therapy for Parkinson disease does not treat hypocretin-deficient cataplexy."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine at bedtime is inappropriate because sedating antihistamines worsen daytime somnolence and do not treat cataplexy."
            },
            {
              "id": "C",
              "text": "Option C: Melatonin alone at bedtime is inappropriate because melatonin may help sleep timing but is not established therapy for cataplexy or narcoleptic sleepiness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Levodopa before emotionally intense activities is inappropriate because dopaminergic therapy for Parkinson disease does not treat hypocretin-deficient cataplexy."
        }
      }
    },
    {
      "externalId": "d5-expansion-sleep-ohs-acute-niv-discharge-001",
      "expectedHashes": {
        "ranaze_step3_uat": "5f0b79b4880578a6f0bcbc84401b35f3d5f2c67110e5a748d4b7ee18efead61c",
        "ranaze_step3_prd": "5f0b79b4880578a6f0bcbc84401b35f3d5f2c67110e5a748d4b7ee18efead61c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase supplemental oxygen alone until saturation is 100% and discharge without positive-airway-pressure therapy is inappropriate because oxygen alone can aggravate CO\u2082 retention and leaves the central problem untreated."
            },
            {
              "id": "B",
              "text": "Option C: Intubate immediately despite preserved airway protection and no NIV trial is inappropriate because intubation is reserved for NIV failure, severe encephalopathy, airway compromise, or instability."
            },
            {
              "id": "C",
              "text": "Option D: Treat with acetazolamide alone and defer positive-airway pressure until substantial weight loss occurs is inappropriate because respiratory stimulants and future weight loss cannot replace immediate ventilatory support."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase supplemental oxygen alone until saturation is 100% and discharge without positive-airway-pressure therapy is inappropriate because oxygen alone can aggravate CO\u2082 retention and leaves the central problem untreated."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intubate immediately despite preserved airway protection and no NIV trial is inappropriate because intubation is reserved for NIV failure, severe encephalopathy, airway compromise, or instability."
            },
            {
              "id": "B",
              "text": "Option B: Increase supplemental oxygen alone until saturation is 100% and discharge without positive-airway-pressure therapy is inappropriate because oxygen alone can aggravate CO\u2082 retention and leaves the central problem untreated."
            },
            {
              "id": "C",
              "text": "Option D: Treat with acetazolamide alone and defer positive-airway pressure until substantial weight loss occurs is inappropriate because respiratory stimulants and future weight loss cannot replace immediate ventilatory support."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intubate immediately despite preserved airway protection and no NIV trial is inappropriate because intubation is reserved for NIV failure, severe encephalopathy, airway compromise, or instability."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with acetazolamide alone and defer positive-airway pressure until substantial weight loss occurs is inappropriate because respiratory stimulants and future weight loss cannot replace immediate ventilatory support."
            },
            {
              "id": "B",
              "text": "Option B: Increase supplemental oxygen alone until saturation is 100% and discharge without positive-airway-pressure therapy is inappropriate because oxygen alone can aggravate CO\u2082 retention and leaves the central problem untreated."
            },
            {
              "id": "C",
              "text": "Option C: Intubate immediately despite preserved airway protection and no NIV trial is inappropriate because intubation is reserved for NIV failure, severe encephalopathy, airway compromise, or instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with acetazolamide alone and defer positive-airway pressure until substantial weight loss occurs is inappropriate because respiratory stimulants and future weight loss cannot replace immediate ventilatory support."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use nocturnal oxygen alone because daytime hypercapnia excludes obstructive sleep apnea is inappropriate because most OHS patients have coexisting OSA, and awake hypercapnia strengthens rather than excludes the diagnosis."
            },
            {
              "id": "B",
              "text": "Option B: Increase supplemental oxygen alone until saturation is 100% and discharge without positive-airway-pressure therapy is inappropriate because oxygen alone can aggravate CO\u2082 retention and leaves the central problem untreated."
            },
            {
              "id": "C",
              "text": "Option C: Intubate immediately despite preserved airway protection and no NIV trial is inappropriate because intubation is reserved for NIV failure, severe encephalopathy, airway compromise, or instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use nocturnal oxygen alone because daytime hypercapnia excludes obstructive sleep apnea is inappropriate because most OHS patients have coexisting OSA, and awake hypercapnia strengthens rather than excludes the diagnosis."
        }
      }
    },
    {
      "externalId": "d5-expansion-sleep-rbd-melatonin-safety-001",
      "expectedHashes": {
        "ranaze_step3_uat": "e052f1377c8b4f01120cef05b7c664aee65f6e9310760992e1d9bb05cd9225c9",
        "ranaze_step3_prd": "e052f1377c8b4f01120cef05b7c664aee65f6e9310760992e1d9bb05cd9225c9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin clonazepam without changing the bedroom because medication eliminates injury risk is inappropriate because no drug eliminates risk, and clonazepam may worsen falls, cognition, and OSA."
            },
            {
              "id": "B",
              "text": "Option C: Prescribe zolpidem to deepen sleep and suppress dream recall is inappropriate because zolpidem is not recommended RBD therapy and may provoke complex sleep behaviors."
            },
            {
              "id": "C",
              "text": "Option D: Stop CPAP because positive airway pressure precipitates REM behavior disorder is inappropriate because oSA treatment should continue; untreated sleep-disordered breathing can worsen sleep fragmentation and mimic behaviors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin clonazepam without changing the bedroom because medication eliminates injury risk is inappropriate because no drug eliminates risk, and clonazepam may worsen falls, cognition, and OSA."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe zolpidem to deepen sleep and suppress dream recall is inappropriate because zolpidem is not recommended RBD therapy and may provoke complex sleep behaviors."
            },
            {
              "id": "B",
              "text": "Option B: Begin clonazepam without changing the bedroom because medication eliminates injury risk is inappropriate because no drug eliminates risk, and clonazepam may worsen falls, cognition, and OSA."
            },
            {
              "id": "C",
              "text": "Option D: Stop CPAP because positive airway pressure precipitates REM behavior disorder is inappropriate because oSA treatment should continue; untreated sleep-disordered breathing can worsen sleep fragmentation and mimic behaviors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe zolpidem to deepen sleep and suppress dream recall is inappropriate because zolpidem is not recommended RBD therapy and may provoke complex sleep behaviors."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop CPAP because positive airway pressure precipitates REM behavior disorder is inappropriate because oSA treatment should continue; untreated sleep-disordered breathing can worsen sleep fragmentation and mimic behaviors."
            },
            {
              "id": "B",
              "text": "Option B: Begin clonazepam without changing the bedroom because medication eliminates injury risk is inappropriate because no drug eliminates risk, and clonazepam may worsen falls, cognition, and OSA."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe zolpidem to deepen sleep and suppress dream recall is inappropriate because zolpidem is not recommended RBD therapy and may provoke complex sleep behaviors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop CPAP because positive airway pressure precipitates REM behavior disorder is inappropriate because oSA treatment should continue; untreated sleep-disordered breathing can worsen sleep fragmentation and mimic behaviors."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassure the couple that dream enactment is harmless and requires no intervention is inappropriate because rBD can seriously injure the patient and bed partner and requires safety planning."
            },
            {
              "id": "B",
              "text": "Option B: Begin clonazepam without changing the bedroom because medication eliminates injury risk is inappropriate because no drug eliminates risk, and clonazepam may worsen falls, cognition, and OSA."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe zolpidem to deepen sleep and suppress dream recall is inappropriate because zolpidem is not recommended RBD therapy and may provoke complex sleep behaviors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassure the couple that dream enactment is harmless and requires no intervention is inappropriate because rBD can seriously injure the patient and bed partner and requires safety planning."
        }
      }
    },
    {
      "externalId": "d5-expansion-urology-emphysematous-pyelonephritis-drainage-001",
      "expectedHashes": {
        "ranaze_step3_uat": "9acfc7befd04f0f16455cc0d9382b7d336e6510375463a031be8b920b582f222",
        "ranaze_step3_prd": "9acfc7befd04f0f16455cc0d9382b7d336e6510375463a031be8b920b582f222"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly to emergency nephrectomy in every patient with renal parenchymal gas is inappropriate because immediate nephrectomy has higher morbidity and is not obligatory when the patient responds to resuscitation and drainage is feasible."
            },
            {
              "id": "B",
              "text": "Option C: Treat with antibiotics alone because the obstruction has resolved is inappropriate because parenchymal and perinephric gas with a large collection requires drainage even without an obstructing stone."
            },
            {
              "id": "C",
              "text": "Option D: Administer oral nitrofurantoin and discharge after defervescence is inappropriate because nitrofurantoin does not reach therapeutic renal parenchymal levels and outpatient care is unsafe."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly to emergency nephrectomy in every patient with renal parenchymal gas is inappropriate because immediate nephrectomy has higher morbidity and is not obligatory when the patient responds to resuscitation and drainage is feasible."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with antibiotics alone because the obstruction has resolved is inappropriate because parenchymal and perinephric gas with a large collection requires drainage even without an obstructing stone."
            },
            {
              "id": "B",
              "text": "Option B: Proceed directly to emergency nephrectomy in every patient with renal parenchymal gas is inappropriate because immediate nephrectomy has higher morbidity and is not obligatory when the patient responds to resuscitation and drainage is feasible."
            },
            {
              "id": "C",
              "text": "Option D: Administer oral nitrofurantoin and discharge after defervescence is inappropriate because nitrofurantoin does not reach therapeutic renal parenchymal levels and outpatient care is unsafe."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with antibiotics alone because the obstruction has resolved is inappropriate because parenchymal and perinephric gas with a large collection requires drainage even without an obstructing stone."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer oral nitrofurantoin and discharge after defervescence is inappropriate because nitrofurantoin does not reach therapeutic renal parenchymal levels and outpatient care is unsafe."
            },
            {
              "id": "B",
              "text": "Option B: Proceed directly to emergency nephrectomy in every patient with renal parenchymal gas is inappropriate because immediate nephrectomy has higher morbidity and is not obligatory when the patient responds to resuscitation and drainage is feasible."
            },
            {
              "id": "C",
              "text": "Option C: Treat with antibiotics alone because the obstruction has resolved is inappropriate because parenchymal and perinephric gas with a large collection requires drainage even without an obstructing stone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer oral nitrofurantoin and discharge after defervescence is inappropriate because nitrofurantoin does not reach therapeutic renal parenchymal levels and outpatient care is unsafe."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin corticosteroids to reduce renal inflammation is inappropriate because steroids worsen uncontrolled infection and have no therapeutic role."
            },
            {
              "id": "B",
              "text": "Option B: Proceed directly to emergency nephrectomy in every patient with renal parenchymal gas is inappropriate because immediate nephrectomy has higher morbidity and is not obligatory when the patient responds to resuscitation and drainage is feasible."
            },
            {
              "id": "C",
              "text": "Option C: Treat with antibiotics alone because the obstruction has resolved is inappropriate because parenchymal and perinephric gas with a large collection requires drainage even without an obstructing stone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin corticosteroids to reduce renal inflammation is inappropriate because steroids worsen uncontrolled infection and have no therapeutic role."
        }
      }
    },
    {
      "externalId": "d5-expansion-urology-fournier-urgent-debridement-001",
      "expectedHashes": {
        "ranaze_step3_uat": "5f2d0a4c0ea3bf3a18c2e3e262cfad0bcb2aa8469ad78f66cf36710f059a1bc9",
        "ranaze_step3_prd": "5f2d0a4c0ea3bf3a18c2e3e262cfad0bcb2aa8469ad78f66cf36710f059a1bc9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain contrast-enhanced CT to define the full extent before surgery is inappropriate because cT must not delay surgery when the clinical diagnosis is already clear."
            },
            {
              "id": "B",
              "text": "Option C: Apply topical antimicrobial dressings and reassess after 6 hours of antibiotics is inappropriate because antibiotics cannot penetrate thrombosed necrotic tissue adequately without debridement."
            },
            {
              "id": "C",
              "text": "Option D: Begin hyperbaric oxygen as definitive treatment before debridement is inappropriate because hyperbaric oxygen lacks consistent evidence and is, at most, an adjunct after source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain contrast-enhanced CT to define the full extent before surgery is inappropriate because cT must not delay surgery when the clinical diagnosis is already clear."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply topical antimicrobial dressings and reassess after 6 hours of antibiotics is inappropriate because antibiotics cannot penetrate thrombosed necrotic tissue adequately without debridement."
            },
            {
              "id": "B",
              "text": "Option B: Obtain contrast-enhanced CT to define the full extent before surgery is inappropriate because cT must not delay surgery when the clinical diagnosis is already clear."
            },
            {
              "id": "C",
              "text": "Option D: Begin hyperbaric oxygen as definitive treatment before debridement is inappropriate because hyperbaric oxygen lacks consistent evidence and is, at most, an adjunct after source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply topical antimicrobial dressings and reassess after 6 hours of antibiotics is inappropriate because antibiotics cannot penetrate thrombosed necrotic tissue adequately without debridement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin hyperbaric oxygen as definitive treatment before debridement is inappropriate because hyperbaric oxygen lacks consistent evidence and is, at most, an adjunct after source control."
            },
            {
              "id": "B",
              "text": "Option B: Obtain contrast-enhanced CT to define the full extent before surgery is inappropriate because cT must not delay surgery when the clinical diagnosis is already clear."
            },
            {
              "id": "C",
              "text": "Option C: Apply topical antimicrobial dressings and reassess after 6 hours of antibiotics is inappropriate because antibiotics cannot penetrate thrombosed necrotic tissue adequately without debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin hyperbaric oxygen as definitive treatment before debridement is inappropriate because hyperbaric oxygen lacks consistent evidence and is, at most, an adjunct after source control."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform needle aspiration of the most fluctuant scrotal area is inappropriate because needle aspiration cannot remove the extensive fascial necrosis."
            },
            {
              "id": "B",
              "text": "Option B: Obtain contrast-enhanced CT to define the full extent before surgery is inappropriate because cT must not delay surgery when the clinical diagnosis is already clear."
            },
            {
              "id": "C",
              "text": "Option C: Apply topical antimicrobial dressings and reassess after 6 hours of antibiotics is inappropriate because antibiotics cannot penetrate thrombosed necrotic tissue adequately without debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform needle aspiration of the most fluctuant scrotal area is inappropriate because needle aspiration cannot remove the extensive fascial necrosis."
        }
      }
    },
    {
      "externalId": "d5-expansion-urology-ischemic-priapism-aspiration-phenylephrine-001",
      "expectedHashes": {
        "ranaze_step3_uat": "14ceadaa465e98f6d33d92be7577ea8e0a4d343b45aca00de5430bcee1fc992c",
        "ranaze_step3_prd": "14ceadaa465e98f6d33d92be7577ea8e0a4d343b45aca00de5430bcee1fc992c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange exchange transfusion before any local penile intervention is inappropriate because exchange transfusion is not routine first-line therapy and must never delay direct treatment."
            },
            {
              "id": "B",
              "text": "Option C: Observe with oxygen and intravenous fluids for another 6 hours is inappropriate because observation risks irreversible corporal necrosis and erectile dysfunction."
            },
            {
              "id": "C",
              "text": "Option D: Apply ice packs and administer oral pseudoephedrine only is inappropriate because oral agents and ice are inadequate after 7 hours of confirmed ischemia; cold may worsen sickling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange exchange transfusion before any local penile intervention is inappropriate because exchange transfusion is not routine first-line therapy and must never delay direct treatment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe with oxygen and intravenous fluids for another 6 hours is inappropriate because observation risks irreversible corporal necrosis and erectile dysfunction."
            },
            {
              "id": "B",
              "text": "Option B: Arrange exchange transfusion before any local penile intervention is inappropriate because exchange transfusion is not routine first-line therapy and must never delay direct treatment."
            },
            {
              "id": "C",
              "text": "Option D: Apply ice packs and administer oral pseudoephedrine only is inappropriate because oral agents and ice are inadequate after 7 hours of confirmed ischemia; cold may worsen sickling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe with oxygen and intravenous fluids for another 6 hours is inappropriate because observation risks irreversible corporal necrosis and erectile dysfunction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply ice packs and administer oral pseudoephedrine only is inappropriate because oral agents and ice are inadequate after 7 hours of confirmed ischemia; cold may worsen sickling."
            },
            {
              "id": "B",
              "text": "Option B: Arrange exchange transfusion before any local penile intervention is inappropriate because exchange transfusion is not routine first-line therapy and must never delay direct treatment."
            },
            {
              "id": "C",
              "text": "Option C: Observe with oxygen and intravenous fluids for another 6 hours is inappropriate because observation risks irreversible corporal necrosis and erectile dysfunction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply ice packs and administer oral pseudoephedrine only is inappropriate because oral agents and ice are inadequate after 7 hours of confirmed ischemia; cold may worsen sickling."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule selective arterial embolization for high-flow priapism is inappropriate because arterial embolization treats nonischemic high-flow priapism, not low-flow ischemia."
            },
            {
              "id": "B",
              "text": "Option B: Arrange exchange transfusion before any local penile intervention is inappropriate because exchange transfusion is not routine first-line therapy and must never delay direct treatment."
            },
            {
              "id": "C",
              "text": "Option C: Observe with oxygen and intravenous fluids for another 6 hours is inappropriate because observation risks irreversible corporal necrosis and erectile dysfunction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule selective arterial embolization for high-flow priapism is inappropriate because arterial embolization treats nonischemic high-flow priapism, not low-flow ischemia."
        }
      }
    },
    {
      "externalId": "d5-hepatology-acute-liver-failure-early-transplant-transfer-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "154d143ada8033e0c8c7b06a2e61e74b24823c1425710afe993e6b2f0989721f",
        "ranaze_step3_prd": "154d143ada8033e0c8c7b06a2e61e74b24823c1425710afe993e6b2f0989721f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait until she satisfies every King\u0027s College criterion before contacting a transplant center is inappropriate because waiting risks losing the safe transfer window."
            },
            {
              "id": "B",
              "text": "Option C: Correct the INR to normal with prophylactic plasma before assessing prognosis is inappropriate because plasma without bleeding masks a key prognostic marker and does not restore hepatic function."
            },
            {
              "id": "C",
              "text": "Option D: Schedule outpatient hepatology follow-up after aminotransferases peak is inappropriate because outpatient management is unsafe with encephalopathy and coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait until she satisfies every King\u0027s College criterion before contacting a transplant center is inappropriate because waiting risks losing the safe transfer window."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Correct the INR to normal with prophylactic plasma before assessing prognosis is inappropriate because plasma without bleeding masks a key prognostic marker and does not restore hepatic function."
            },
            {
              "id": "B",
              "text": "Option A: Wait until she satisfies every King\u0027s College criterion before contacting a transplant center is inappropriate because waiting risks losing the safe transfer window."
            },
            {
              "id": "C",
              "text": "Option D: Schedule outpatient hepatology follow-up after aminotransferases peak is inappropriate because outpatient management is unsafe with encephalopathy and coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Correct the INR to normal with prophylactic plasma before assessing prognosis is inappropriate because plasma without bleeding masks a key prognostic marker and does not restore hepatic function."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule outpatient hepatology follow-up after aminotransferases peak is inappropriate because outpatient management is unsafe with encephalopathy and coagulopathy."
            },
            {
              "id": "B",
              "text": "Option A: Wait until she satisfies every King\u0027s College criterion before contacting a transplant center is inappropriate because waiting risks losing the safe transfer window."
            },
            {
              "id": "C",
              "text": "Option C: Correct the INR to normal with prophylactic plasma before assessing prognosis is inappropriate because plasma without bleeding masks a key prognostic marker and does not restore hepatic function."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule outpatient hepatology follow-up after aminotransferases peak is inappropriate because outpatient management is unsafe with encephalopathy and coagulopathy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin corticosteroids for presumed autoimmune hepatitis without further evaluation is inappropriate because the exposure and biochemical pattern require acetaminophen-directed care, not empiric steroid delay."
            },
            {
              "id": "B",
              "text": "Option A: Wait until she satisfies every King\u0027s College criterion before contacting a transplant center is inappropriate because waiting risks losing the safe transfer window."
            },
            {
              "id": "C",
              "text": "Option C: Correct the INR to normal with prophylactic plasma before assessing prognosis is inappropriate because plasma without bleeding masks a key prognostic marker and does not restore hepatic function."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin corticosteroids for presumed autoimmune hepatitis without further evaluation is inappropriate because the exposure and biochemical pattern require acetaminophen-directed care, not empiric steroid delay."
        }
      }
    },
    {
      "externalId": "d5-hepatology-high-risk-variceal-bleed-preemptive-tips-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "06935433094b73e481d9d789742ba6b879c957b6173e7297231a9623937a0a4f",
        "ranaze_step3_prd": "06935433094b73e481d9d789742ba6b879c957b6173e7297231a9623937a0a4f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop vasoactive therapy and discharge him after 12 hours is inappropriate because high-risk patients require ongoing inpatient therapy and definitive risk reduction."
            },
            {
              "id": "B",
              "text": "Option C: Wait for recurrent bleeding before considering portal decompression is inappropriate because waiting converts a planned mortality-reducing strategy into rescue treatment."
            },
            {
              "id": "C",
              "text": "Option D: Start aspirin to prevent portal-vein thrombosis is inappropriate because aspirin does not prevent recurrent variceal hemorrhage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop vasoactive therapy and discharge him after 12 hours is inappropriate because high-risk patients require ongoing inpatient therapy and definitive risk reduction."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for recurrent bleeding before considering portal decompression is inappropriate because waiting converts a planned mortality-reducing strategy into rescue treatment."
            },
            {
              "id": "B",
              "text": "Option A: Stop vasoactive therapy and discharge him after 12 hours is inappropriate because high-risk patients require ongoing inpatient therapy and definitive risk reduction."
            },
            {
              "id": "C",
              "text": "Option D: Start aspirin to prevent portal-vein thrombosis is inappropriate because aspirin does not prevent recurrent variceal hemorrhage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for recurrent bleeding before considering portal decompression is inappropriate because waiting converts a planned mortality-reducing strategy into rescue treatment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start aspirin to prevent portal-vein thrombosis is inappropriate because aspirin does not prevent recurrent variceal hemorrhage."
            },
            {
              "id": "B",
              "text": "Option A: Stop vasoactive therapy and discharge him after 12 hours is inappropriate because high-risk patients require ongoing inpatient therapy and definitive risk reduction."
            },
            {
              "id": "C",
              "text": "Option C: Wait for recurrent bleeding before considering portal decompression is inappropriate because waiting converts a planned mortality-reducing strategy into rescue treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start aspirin to prevent portal-vein thrombosis is inappropriate because aspirin does not prevent recurrent variceal hemorrhage."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform elective splenectomy is inappropriate because splenectomy is not standard portal decompression for cirrhotic variceal bleeding."
            },
            {
              "id": "B",
              "text": "Option A: Stop vasoactive therapy and discharge him after 12 hours is inappropriate because high-risk patients require ongoing inpatient therapy and definitive risk reduction."
            },
            {
              "id": "C",
              "text": "Option C: Wait for recurrent bleeding before considering portal decompression is inappropriate because waiting converts a planned mortality-reducing strategy into rescue treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform elective splenectomy is inappropriate because splenectomy is not standard portal decompression for cirrhotic variceal bleeding."
        }
      }
    },
    {
      "externalId": "d5-hepatology-resolved-hbv-rituximab-antiviral-prophylaxis-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "8ebfc8a103b678959968f166362d25c840f6619176ffc81ba6e0c891947c6d4b",
        "ranaze_step3_prd": "8ebfc8a103b678959968f166362d25c840f6619176ffc81ba6e0c891947c6d4b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No action because anti-HBs proves complete protection during rituximab therapy is inappropriate because anti-HBs may not prevent reactivation under profound B-cell depletion."
            },
            {
              "id": "B",
              "text": "Option C: Give a hepatitis B vaccine booster as the only intervention is inappropriate because vaccination cannot eradicate latent intrahepatic HBV templates."
            },
            {
              "id": "C",
              "text": "Option D: Monitor ALT alone and start treatment only if jaundice develops is inappropriate because aLT-only monitoring detects injury late and omits virologic surveillance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No action because anti-HBs proves complete protection during rituximab therapy is inappropriate because anti-HBs may not prevent reactivation under profound B-cell depletion."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give a hepatitis B vaccine booster as the only intervention is inappropriate because vaccination cannot eradicate latent intrahepatic HBV templates."
            },
            {
              "id": "B",
              "text": "Option A: No action because anti-HBs proves complete protection during rituximab therapy is inappropriate because anti-HBs may not prevent reactivation under profound B-cell depletion."
            },
            {
              "id": "C",
              "text": "Option D: Monitor ALT alone and start treatment only if jaundice develops is inappropriate because aLT-only monitoring detects injury late and omits virologic surveillance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give a hepatitis B vaccine booster as the only intervention is inappropriate because vaccination cannot eradicate latent intrahepatic HBV templates."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Monitor ALT alone and start treatment only if jaundice develops is inappropriate because aLT-only monitoring detects injury late and omits virologic surveillance."
            },
            {
              "id": "B",
              "text": "Option A: No action because anti-HBs proves complete protection during rituximab therapy is inappropriate because anti-HBs may not prevent reactivation under profound B-cell depletion."
            },
            {
              "id": "C",
              "text": "Option C: Give a hepatitis B vaccine booster as the only intervention is inappropriate because vaccination cannot eradicate latent intrahepatic HBV templates."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Monitor ALT alone and start treatment only if jaundice develops is inappropriate because aLT-only monitoring detects injury late and omits virologic surveillance."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Substitute lamivudine because a low resistance barrier is preferred for prophylaxis is inappropriate because lamivudine resistance makes high-barrier agents preferable."
            },
            {
              "id": "B",
              "text": "Option A: No action because anti-HBs proves complete protection during rituximab therapy is inappropriate because anti-HBs may not prevent reactivation under profound B-cell depletion."
            },
            {
              "id": "C",
              "text": "Option C: Give a hepatitis B vaccine booster as the only intervention is inappropriate because vaccination cannot eradicate latent intrahepatic HBV templates."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Substitute lamivudine because a low resistance barrier is preferred for prophylaxis is inappropriate because lamivudine resistance makes high-barrier agents preferable."
        }
      }
    },
    {
      "externalId": "d5-infectious-cied-endocarditis-complete-system-extraction-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "123b62acf062d3c01363628f581129171062822bedcf0ce49d5da6a9ec65c0fb",
        "ranaze_step3_prd": "123b62acf062d3c01363628f581129171062822bedcf0ce49d5da6a9ec65c0fb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with antibiotics alone because lead extraction is riskier than retaining infected hardware is inappropriate because antibiotics alone leave infected biofilm and are associated with relapse and excess mortality."
            },
            {
              "id": "B",
              "text": "Option C: Remove only the exposed generator and leave the intravascular leads in place is inappropriate because retained intravascular leads remain a nidus for bacteremia and endocarditis."
            },
            {
              "id": "C",
              "text": "Option D: Exchange the generator over the same leads during active bacteremia is inappropriate because reusing infected leads and operating during bacteremia seeds the replacement system."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with antibiotics alone because lead extraction is riskier than retaining infected hardware is inappropriate because antibiotics alone leave infected biofilm and are associated with relapse and excess mortality."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remove only the exposed generator and leave the intravascular leads in place is inappropriate because retained intravascular leads remain a nidus for bacteremia and endocarditis."
            },
            {
              "id": "B",
              "text": "Option B: Treat with antibiotics alone because lead extraction is riskier than retaining infected hardware is inappropriate because antibiotics alone leave infected biofilm and are associated with relapse and excess mortality."
            },
            {
              "id": "C",
              "text": "Option D: Exchange the generator over the same leads during active bacteremia is inappropriate because reusing infected leads and operating during bacteremia seeds the replacement system."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remove only the exposed generator and leave the intravascular leads in place is inappropriate because retained intravascular leads remain a nidus for bacteremia and endocarditis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exchange the generator over the same leads during active bacteremia is inappropriate because reusing infected leads and operating during bacteremia seeds the replacement system."
            },
            {
              "id": "B",
              "text": "Option B: Treat with antibiotics alone because lead extraction is riskier than retaining infected hardware is inappropriate because antibiotics alone leave infected biofilm and are associated with relapse and excess mortality."
            },
            {
              "id": "C",
              "text": "Option C: Remove only the exposed generator and leave the intravascular leads in place is inappropriate because retained intravascular leads remain a nidus for bacteremia and endocarditis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exchange the generator over the same leads during active bacteremia is inappropriate because reusing infected leads and operating during bacteremia seeds the replacement system."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply topical antibiotics to the pocket and continue the existing system is inappropriate because pocket erosion denotes deep system involvement, not superficial cellulitis."
            },
            {
              "id": "B",
              "text": "Option B: Treat with antibiotics alone because lead extraction is riskier than retaining infected hardware is inappropriate because antibiotics alone leave infected biofilm and are associated with relapse and excess mortality."
            },
            {
              "id": "C",
              "text": "Option C: Remove only the exposed generator and leave the intravascular leads in place is inappropriate because retained intravascular leads remain a nidus for bacteremia and endocarditis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply topical antibiotics to the pocket and continue the existing system is inappropriate because pocket erosion denotes deep system involvement, not superficial cellulitis."
        }
      }
    },
    {
      "externalId": "d5-infectious-febrile-neutropenic-shock-catheter-coverage-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "6373dbed1d15643441ced5ca79212b758a3ea2e797b2dbbb5e2a31c66f5f06bb",
        "ranaze_step3_prd": "6373dbed1d15643441ced5ca79212b758a3ea2e797b2dbbb5e2a31c66f5f06bb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for culture identification because fever may be the only manifestation of infection in neutropenia is inappropriate because waiting for cultures in neutropenic shock increases mortality and ignores the urgency of empiric therapy."
            },
            {
              "id": "B",
              "text": "Option C: Use oral ciprofloxacin and amoxicillin-clavulanate as outpatient therapy is inappropriate because outpatient oral therapy is contraindicated by shock, profound neutropenia, leukemia induction, and catheter findings."
            },
            {
              "id": "C",
              "text": "Option D: Give vancomycin alone because the catheter is erythematous is inappropriate because vancomycin lacks reliable gram-negative and Pseudomonas coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for culture identification because fever may be the only manifestation of infection in neutropenia is inappropriate because waiting for cultures in neutropenic shock increases mortality and ignores the urgency of empiric therapy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use oral ciprofloxacin and amoxicillin-clavulanate as outpatient therapy is inappropriate because outpatient oral therapy is contraindicated by shock, profound neutropenia, leukemia induction, and catheter findings."
            },
            {
              "id": "B",
              "text": "Option B: Wait for culture identification because fever may be the only manifestation of infection in neutropenia is inappropriate because waiting for cultures in neutropenic shock increases mortality and ignores the urgency of empiric therapy."
            },
            {
              "id": "C",
              "text": "Option D: Give vancomycin alone because the catheter is erythematous is inappropriate because vancomycin lacks reliable gram-negative and Pseudomonas coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use oral ciprofloxacin and amoxicillin-clavulanate as outpatient therapy is inappropriate because outpatient oral therapy is contraindicated by shock, profound neutropenia, leukemia induction, and catheter findings."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give vancomycin alone because the catheter is erythematous is inappropriate because vancomycin lacks reliable gram-negative and Pseudomonas coverage."
            },
            {
              "id": "B",
              "text": "Option B: Wait for culture identification because fever may be the only manifestation of infection in neutropenia is inappropriate because waiting for cultures in neutropenic shock increases mortality and ignores the urgency of empiric therapy."
            },
            {
              "id": "C",
              "text": "Option C: Use oral ciprofloxacin and amoxicillin-clavulanate as outpatient therapy is inappropriate because outpatient oral therapy is contraindicated by shock, profound neutropenia, leukemia induction, and catheter findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give vancomycin alone because the catheter is erythematous is inappropriate because vancomycin lacks reliable gram-negative and Pseudomonas coverage."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start empiric antifungal monotherapy and omit antibacterial coverage is inappropriate because fungi are not adequate targets for sole initial therapy in acute febrile neutropenia."
            },
            {
              "id": "B",
              "text": "Option B: Wait for culture identification because fever may be the only manifestation of infection in neutropenia is inappropriate because waiting for cultures in neutropenic shock increases mortality and ignores the urgency of empiric therapy."
            },
            {
              "id": "C",
              "text": "Option C: Use oral ciprofloxacin and amoxicillin-clavulanate as outpatient therapy is inappropriate because outpatient oral therapy is contraindicated by shock, profound neutropenia, leukemia induction, and catheter findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start empiric antifungal monotherapy and omit antibacterial coverage is inappropriate because fungi are not adequate targets for sole initial therapy in acute febrile neutropenia."
        }
      }
    },
    {
      "externalId": "d5-infectious-neutropenic-enterocolitis-conservative-first-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "534d5af096d4c623d3174c27f9a710c740dca0d9b8ec5064d3f7b8ffb5f6710a",
        "ranaze_step3_prd": "534d5af096d4c623d3174c27f9a710c740dca0d9b8ec5064d3f7b8ffb5f6710a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate right hemicolectomy solely because bowel-wall thickening exceeds 10 mm is inappropriate because wall thickness predicts severity but is not by itself an indication for immediate colectomy in a stable patient."
            },
            {
              "id": "B",
              "text": "Option C: Urgent colonoscopy with biopsy through the inflamed cecum is inappropriate because instrumentation of friable neutropenic bowel carries substantial perforation and bleeding risk."
            },
            {
              "id": "C",
              "text": "Option D: Loperamide and continued enteral feeding to prevent malnutrition is inappropriate because antimotility therapy and ongoing feeds can worsen distention, ileus, and mucosal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate right hemicolectomy solely because bowel-wall thickening exceeds 10 mm is inappropriate because wall thickness predicts severity but is not by itself an indication for immediate colectomy in a stable patient."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urgent colonoscopy with biopsy through the inflamed cecum is inappropriate because instrumentation of friable neutropenic bowel carries substantial perforation and bleeding risk."
            },
            {
              "id": "B",
              "text": "Option B: Immediate right hemicolectomy solely because bowel-wall thickening exceeds 10 mm is inappropriate because wall thickness predicts severity but is not by itself an indication for immediate colectomy in a stable patient."
            },
            {
              "id": "C",
              "text": "Option D: Loperamide and continued enteral feeding to prevent malnutrition is inappropriate because antimotility therapy and ongoing feeds can worsen distention, ileus, and mucosal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urgent colonoscopy with biopsy through the inflamed cecum is inappropriate because instrumentation of friable neutropenic bowel carries substantial perforation and bleeding risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Loperamide and continued enteral feeding to prevent malnutrition is inappropriate because antimotility therapy and ongoing feeds can worsen distention, ileus, and mucosal injury."
            },
            {
              "id": "B",
              "text": "Option B: Immediate right hemicolectomy solely because bowel-wall thickening exceeds 10 mm is inappropriate because wall thickness predicts severity but is not by itself an indication for immediate colectomy in a stable patient."
            },
            {
              "id": "C",
              "text": "Option C: Urgent colonoscopy with biopsy through the inflamed cecum is inappropriate because instrumentation of friable neutropenic bowel carries substantial perforation and bleeding risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Loperamide and continued enteral feeding to prevent malnutrition is inappropriate because antimotility therapy and ongoing feeds can worsen distention, ileus, and mucosal injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral vancomycin alone despite negative C difficile testing is inappropriate because the syndrome is polymicrobial and requires systemic broad-spectrum coverage, not isolated C difficile therapy."
            },
            {
              "id": "B",
              "text": "Option B: Immediate right hemicolectomy solely because bowel-wall thickening exceeds 10 mm is inappropriate because wall thickness predicts severity but is not by itself an indication for immediate colectomy in a stable patient."
            },
            {
              "id": "C",
              "text": "Option C: Urgent colonoscopy with biopsy through the inflamed cecum is inappropriate because instrumentation of friable neutropenic bowel carries substantial perforation and bleeding risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral vancomycin alone despite negative C difficile testing is inappropriate because the syndrome is polymicrobial and requires systemic broad-spectrum coverage, not isolated C difficile therapy."
        }
      }
    },
    {
      "externalId": "d5-infectious-respiratory-diphtheria-antitoxin-antibiotic-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "935d8b320ddecc0724fc5a993242b56b98a0f18e37350b87308d854e4d0ac370",
        "ranaze_step3_prd": "935d8b320ddecc0724fc5a993242b56b98a0f18e37350b87308d854e4d0ac370"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Await culture and toxin results before treatment is inappropriate because waiting permits irreversible toxin binding and progression."
            },
            {
              "id": "B",
              "text": "Option C: Give antibiotics alone because antitoxin cannot affect circulating toxin is inappropriate because antibiotics do not neutralize toxin already released."
            },
            {
              "id": "C",
              "text": "Option D: Attempt vigorous mechanical removal of the membrane is inappropriate because membrane manipulation can cause hemorrhage and airway obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Await culture and toxin results before treatment is inappropriate because waiting permits irreversible toxin binding and progression."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give antibiotics alone because antitoxin cannot affect circulating toxin is inappropriate because antibiotics do not neutralize toxin already released."
            },
            {
              "id": "B",
              "text": "Option A: Await culture and toxin results before treatment is inappropriate because waiting permits irreversible toxin binding and progression."
            },
            {
              "id": "C",
              "text": "Option D: Attempt vigorous mechanical removal of the membrane is inappropriate because membrane manipulation can cause hemorrhage and airway obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give antibiotics alone because antitoxin cannot affect circulating toxin is inappropriate because antibiotics do not neutralize toxin already released."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Attempt vigorous mechanical removal of the membrane is inappropriate because membrane manipulation can cause hemorrhage and airway obstruction."
            },
            {
              "id": "B",
              "text": "Option A: Await culture and toxin results before treatment is inappropriate because waiting permits irreversible toxin binding and progression."
            },
            {
              "id": "C",
              "text": "Option C: Give antibiotics alone because antitoxin cannot affect circulating toxin is inappropriate because antibiotics do not neutralize toxin already released."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Attempt vigorous mechanical removal of the membrane is inappropriate because membrane manipulation can cause hemorrhage and airway obstruction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer vaccine alone as treatment of the acute illness is inappropriate because vaccination prevents future disease but does not neutralize current toxin."
            },
            {
              "id": "B",
              "text": "Option A: Await culture and toxin results before treatment is inappropriate because waiting permits irreversible toxin binding and progression."
            },
            {
              "id": "C",
              "text": "Option C: Give antibiotics alone because antitoxin cannot affect circulating toxin is inappropriate because antibiotics do not neutralize toxin already released."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer vaccine alone as treatment of the acute illness is inappropriate because vaccination prevents future disease but does not neutralize current toxin."
        }
      }
    },
    {
      "externalId": "d5-infectious-severe-falciparum-malaria-iv-artesunate-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "174eec08e0dee62cdfd75b4ae47c7d99adabacdded62488c2028049a4fec2fa7",
        "ranaze_step3_prd": "174eec08e0dee62cdfd75b4ae47c7d99adabacdded62488c2028049a4fec2fa7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral atovaquone-proguanil alone is inappropriate because oral therapy alone is inadequate in severe disease."
            },
            {
              "id": "B",
              "text": "Option C: Exchange transfusion as the preferred first-line treatment is inappropriate because cDC no longer recommends exchange transfusion."
            },
            {
              "id": "C",
              "text": "Option D: Oral chloroquine is inappropriate because falciparum malaria from Nigeria is often chloroquine resistant, and severity mandates IV therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral atovaquone-proguanil alone is inappropriate because oral therapy alone is inadequate in severe disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exchange transfusion as the preferred first-line treatment is inappropriate because cDC no longer recommends exchange transfusion."
            },
            {
              "id": "B",
              "text": "Option A: Oral atovaquone-proguanil alone is inappropriate because oral therapy alone is inadequate in severe disease."
            },
            {
              "id": "C",
              "text": "Option D: Oral chloroquine is inappropriate because falciparum malaria from Nigeria is often chloroquine resistant, and severity mandates IV therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exchange transfusion as the preferred first-line treatment is inappropriate because cDC no longer recommends exchange transfusion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral chloroquine is inappropriate because falciparum malaria from Nigeria is often chloroquine resistant, and severity mandates IV therapy."
            },
            {
              "id": "B",
              "text": "Option A: Oral atovaquone-proguanil alone is inappropriate because oral therapy alone is inadequate in severe disease."
            },
            {
              "id": "C",
              "text": "Option C: Exchange transfusion as the preferred first-line treatment is inappropriate because cDC no longer recommends exchange transfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral chloroquine is inappropriate because falciparum malaria from Nigeria is often chloroquine resistant, and severity mandates IV therapy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay therapy until species confirmation by polymerase chain reaction is inappropriate because severe malaria treatment cannot wait for molecular confirmation."
            },
            {
              "id": "B",
              "text": "Option A: Oral atovaquone-proguanil alone is inappropriate because oral therapy alone is inadequate in severe disease."
            },
            {
              "id": "C",
              "text": "Option C: Exchange transfusion as the preferred first-line treatment is inappropriate because cDC no longer recommends exchange transfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay therapy until species confirmation by polymerase chain reaction is inappropriate because severe malaria treatment cannot wait for molecular confirmation."
        }
      }
    },
    {
      "externalId": "d5-infectious-wound-botulism-antitoxin-now-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "70eadbbca3de4ef6339810e3f5d04cdc573bfe3fa5996e23a092b01d81a527c8",
        "ranaze_step3_prd": "70eadbbca3de4ef6339810e3f5d04cdc573bfe3fa5996e23a092b01d81a527c8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for toxin confirmation before initiating specific therapy is inappropriate because delayed treatment increases paralysis and ventilatory failure."
            },
            {
              "id": "B",
              "text": "Option C: Administer pyridostigmine alone and discharge if ptosis improves is inappropriate because pyridostigmine does not neutralize toxin and discharge is unsafe with declining vital capacity."
            },
            {
              "id": "C",
              "text": "Option D: Give an aminoglycoside as first-line monotherapy is inappropriate because aminoglycosides may aggravate neuromuscular weakness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for toxin confirmation before initiating specific therapy is inappropriate because delayed treatment increases paralysis and ventilatory failure."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer pyridostigmine alone and discharge if ptosis improves is inappropriate because pyridostigmine does not neutralize toxin and discharge is unsafe with declining vital capacity."
            },
            {
              "id": "B",
              "text": "Option A: Wait for toxin confirmation before initiating specific therapy is inappropriate because delayed treatment increases paralysis and ventilatory failure."
            },
            {
              "id": "C",
              "text": "Option D: Give an aminoglycoside as first-line monotherapy is inappropriate because aminoglycosides may aggravate neuromuscular weakness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer pyridostigmine alone and discharge if ptosis improves is inappropriate because pyridostigmine does not neutralize toxin and discharge is unsafe with declining vital capacity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give an aminoglycoside as first-line monotherapy is inappropriate because aminoglycosides may aggravate neuromuscular weakness."
            },
            {
              "id": "B",
              "text": "Option A: Wait for toxin confirmation before initiating specific therapy is inappropriate because delayed treatment increases paralysis and ventilatory failure."
            },
            {
              "id": "C",
              "text": "Option C: Administer pyridostigmine alone and discharge if ptosis improves is inappropriate because pyridostigmine does not neutralize toxin and discharge is unsafe with declining vital capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give an aminoglycoside as first-line monotherapy is inappropriate because aminoglycosides may aggravate neuromuscular weakness."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform plasma exchange is inappropriate because plasma exchange has no established benefit."
            },
            {
              "id": "B",
              "text": "Option A: Wait for toxin confirmation before initiating specific therapy is inappropriate because delayed treatment increases paralysis and ventilatory failure."
            },
            {
              "id": "C",
              "text": "Option C: Administer pyridostigmine alone and discharge if ptosis improves is inappropriate because pyridostigmine does not neutralize toxin and discharge is unsafe with declining vital capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform plasma exchange is inappropriate because plasma exchange has no established benefit."
        }
      }
    },
    {
      "externalId": "d5-neurology-aneurysmal-sah-nimodipine-early-securing-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "0fd9c5155d3fc7980b9a8fa9b1ccdfd0efff5e8e47d8b3e929eb28074a6e50c9",
        "ranaze_step3_prd": "0fd9c5155d3fc7980b9a8fa9b1ccdfd0efff5e8e47d8b3e929eb28074a6e50c9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Induce prophylactic hypertension and hypervolemia before the aneurysm is secured is inappropriate because prophylactic hypertension and hypervolemia increase complications and can increase rerupture risk before obliteration."
            },
            {
              "id": "B",
              "text": "Option C: Delay aneurysm treatment for 14 days while giving intravenous magnesium is inappropriate because delaying closure prolongs the highest-risk period for rerupture, and routine IV magnesium is not recommended."
            },
            {
              "id": "C",
              "text": "Option D: Give routine antifibrinolytic therapy indefinitely and omit aneurysm obliteration is inappropriate because antifibrinolytics do not replace definitive aneurysm treatment and routine prolonged use does not improve functional outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Induce prophylactic hypertension and hypervolemia before the aneurysm is secured is inappropriate because prophylactic hypertension and hypervolemia increase complications and can increase rerupture risk before obliteration."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay aneurysm treatment for 14 days while giving intravenous magnesium is inappropriate because delaying closure prolongs the highest-risk period for rerupture, and routine IV magnesium is not recommended."
            },
            {
              "id": "B",
              "text": "Option B: Induce prophylactic hypertension and hypervolemia before the aneurysm is secured is inappropriate because prophylactic hypertension and hypervolemia increase complications and can increase rerupture risk before obliteration."
            },
            {
              "id": "C",
              "text": "Option D: Give routine antifibrinolytic therapy indefinitely and omit aneurysm obliteration is inappropriate because antifibrinolytics do not replace definitive aneurysm treatment and routine prolonged use does not improve functional outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay aneurysm treatment for 14 days while giving intravenous magnesium is inappropriate because delaying closure prolongs the highest-risk period for rerupture, and routine IV magnesium is not recommended."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give routine antifibrinolytic therapy indefinitely and omit aneurysm obliteration is inappropriate because antifibrinolytics do not replace definitive aneurysm treatment and routine prolonged use does not improve functional outcomes."
            },
            {
              "id": "B",
              "text": "Option B: Induce prophylactic hypertension and hypervolemia before the aneurysm is secured is inappropriate because prophylactic hypertension and hypervolemia increase complications and can increase rerupture risk before obliteration."
            },
            {
              "id": "C",
              "text": "Option C: Delay aneurysm treatment for 14 days while giving intravenous magnesium is inappropriate because delaying closure prolongs the highest-risk period for rerupture, and routine IV magnesium is not recommended."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give routine antifibrinolytic therapy indefinitely and omit aneurysm obliteration is inappropriate because antifibrinolytics do not replace definitive aneurysm treatment and routine prolonged use does not improve functional outcomes."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold nimodipine until transcranial Doppler proves vasospasm is inappropriate because nimodipine is preventive and should be started early rather than after vasospasm is documented."
            },
            {
              "id": "B",
              "text": "Option B: Induce prophylactic hypertension and hypervolemia before the aneurysm is secured is inappropriate because prophylactic hypertension and hypervolemia increase complications and can increase rerupture risk before obliteration."
            },
            {
              "id": "C",
              "text": "Option C: Delay aneurysm treatment for 14 days while giving intravenous magnesium is inappropriate because delaying closure prolongs the highest-risk period for rerupture, and routine IV magnesium is not recommended."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold nimodipine until transcranial Doppler proves vasospasm is inappropriate because nimodipine is preventive and should be started early rather than after vasospasm is documented."
        }
      }
    },
    {
      "externalId": "d5-neurology-cerebellar-infarct-swelling-decompression-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "bc81994962bf8a8f1d160b97f368e83da645c93e406e5c95615dc3df5cd6110b",
        "ranaze_step3_prd": "bc81994962bf8a8f1d160b97f368e83da645c93e406e5c95615dc3df5cd6110b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remove the ventricular drain and observe for spontaneous edema resolution is inappropriate because removing CSF diversion worsens hydrocephalus and observation risks irreversible herniation."
            },
            {
              "id": "B",
              "text": "Option C: Give therapeutic heparin to dissolve the edematous infarct is inappropriate because heparin cannot reverse infarct edema and adds hemorrhagic-transformation risk."
            },
            {
              "id": "C",
              "text": "Option D: Perform lumbar puncture to reduce posterior-fossa pressure is inappropriate because lumbar CSF removal creates a dangerous pressure gradient in posterior-fossa mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remove the ventricular drain and observe for spontaneous edema resolution is inappropriate because removing CSF diversion worsens hydrocephalus and observation risks irreversible herniation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give therapeutic heparin to dissolve the edematous infarct is inappropriate because heparin cannot reverse infarct edema and adds hemorrhagic-transformation risk."
            },
            {
              "id": "B",
              "text": "Option B: Remove the ventricular drain and observe for spontaneous edema resolution is inappropriate because removing CSF diversion worsens hydrocephalus and observation risks irreversible herniation."
            },
            {
              "id": "C",
              "text": "Option D: Perform lumbar puncture to reduce posterior-fossa pressure is inappropriate because lumbar CSF removal creates a dangerous pressure gradient in posterior-fossa mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give therapeutic heparin to dissolve the edematous infarct is inappropriate because heparin cannot reverse infarct edema and adds hemorrhagic-transformation risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform lumbar puncture to reduce posterior-fossa pressure is inappropriate because lumbar CSF removal creates a dangerous pressure gradient in posterior-fossa mass effect."
            },
            {
              "id": "B",
              "text": "Option B: Remove the ventricular drain and observe for spontaneous edema resolution is inappropriate because removing CSF diversion worsens hydrocephalus and observation risks irreversible herniation."
            },
            {
              "id": "C",
              "text": "Option C: Give therapeutic heparin to dissolve the edematous infarct is inappropriate because heparin cannot reverse infarct edema and adds hemorrhagic-transformation risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform lumbar puncture to reduce posterior-fossa pressure is inappropriate because lumbar CSF removal creates a dangerous pressure gradient in posterior-fossa mass effect."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin long-term dexamethasone as definitive treatment for cytotoxic stroke edema is inappropriate because steroids are useful for vasogenic tumor edema, not cytotoxic ischemic edema."
            },
            {
              "id": "B",
              "text": "Option B: Remove the ventricular drain and observe for spontaneous edema resolution is inappropriate because removing CSF diversion worsens hydrocephalus and observation risks irreversible herniation."
            },
            {
              "id": "C",
              "text": "Option C: Give therapeutic heparin to dissolve the edematous infarct is inappropriate because heparin cannot reverse infarct edema and adds hemorrhagic-transformation risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin long-term dexamethasone as definitive treatment for cytotoxic stroke edema is inappropriate because steroids are useful for vasogenic tumor edema, not cytotoxic ischemic edema."
        }
      }
    },
    {
      "externalId": "d5-neurology-guillain-barre-impending-respiratory-failure-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "8ee8bf2d8db69a576f65dcc0a5654cedcc5db146d75b03471cd0a46403a09332",
        "ranaze_step3_prd": "8ee8bf2d8db69a576f65dcc0a5654cedcc5db146d75b03471cd0a46403a09332"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for oxygen desaturation or hypercapnia before securing the airway is inappropriate because hypoxemia and hypercapnia are late findings after respiratory muscle reserve has failed."
            },
            {
              "id": "B",
              "text": "Option C: Give high-dose corticosteroids as sole disease-modifying therapy is inappropriate because steroids do not improve GBS outcomes."
            },
            {
              "id": "C",
              "text": "Option D: Use succinylcholine for rapid-sequence intubation because denervated muscle is potassium-depleted is inappropriate because succinylcholine can provoke lethal hyperkalemia in denervation disorders."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for oxygen desaturation or hypercapnia before securing the airway is inappropriate because hypoxemia and hypercapnia are late findings after respiratory muscle reserve has failed."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give high-dose corticosteroids as sole disease-modifying therapy is inappropriate because steroids do not improve GBS outcomes."
            },
            {
              "id": "B",
              "text": "Option B: Wait for oxygen desaturation or hypercapnia before securing the airway is inappropriate because hypoxemia and hypercapnia are late findings after respiratory muscle reserve has failed."
            },
            {
              "id": "C",
              "text": "Option D: Use succinylcholine for rapid-sequence intubation because denervated muscle is potassium-depleted is inappropriate because succinylcholine can provoke lethal hyperkalemia in denervation disorders."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give high-dose corticosteroids as sole disease-modifying therapy is inappropriate because steroids do not improve GBS outcomes."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use succinylcholine for rapid-sequence intubation because denervated muscle is potassium-depleted is inappropriate because succinylcholine can provoke lethal hyperkalemia in denervation disorders."
            },
            {
              "id": "B",
              "text": "Option B: Wait for oxygen desaturation or hypercapnia before securing the airway is inappropriate because hypoxemia and hypercapnia are late findings after respiratory muscle reserve has failed."
            },
            {
              "id": "C",
              "text": "Option C: Give high-dose corticosteroids as sole disease-modifying therapy is inappropriate because steroids do not improve GBS outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use succinylcholine for rapid-sequence intubation because denervated muscle is potassium-depleted is inappropriate because succinylcholine can provoke lethal hyperkalemia in denervation disorders."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with outpatient spirometry because the arterial blood gas is normal is inappropriate because normal gas exchange does not offset rapidly worsening mechanics and autonomic instability."
            },
            {
              "id": "B",
              "text": "Option B: Wait for oxygen desaturation or hypercapnia before securing the airway is inappropriate because hypoxemia and hypercapnia are late findings after respiratory muscle reserve has failed."
            },
            {
              "id": "C",
              "text": "Option C: Give high-dose corticosteroids as sole disease-modifying therapy is inappropriate because steroids do not improve GBS outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with outpatient spirometry because the arterial blood gas is normal is inappropriate because normal gas exchange does not offset rapidly worsening mechanics and autonomic instability."
        }
      }
    },
    {
      "externalId": "d5-obstetrics-acute-fatty-liver-pregnancy-correct-and-deliver-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "cbca3806a43c11b6dc7c1a8ea7fd811885b9e077f6d863a2ce5758c537813327",
        "ranaze_step3_prd": "cbca3806a43c11b6dc7c1a8ea7fd811885b9e077f6d863a2ce5758c537813327"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe until spontaneous labor because fetal status is reassuring is inappropriate because maternal deterioration can be rapid despite a reassuring fetus."
            },
            {
              "id": "B",
              "text": "Option C: Start high-dose corticosteroids and delay delivery until aminotransferases normalize is inappropriate because steroids do not reverse hepatic microvesicular steatosis, and biochemical normalization follows delivery rather than preceding it."
            },
            {
              "id": "C",
              "text": "Option D: Perform percutaneous liver biopsy before any obstetric intervention is inappropriate because coagulopathy makes biopsy dangerous, and the clinical syndrome is sufficient to act."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe until spontaneous labor because fetal status is reassuring is inappropriate because maternal deterioration can be rapid despite a reassuring fetus."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start high-dose corticosteroids and delay delivery until aminotransferases normalize is inappropriate because steroids do not reverse hepatic microvesicular steatosis, and biochemical normalization follows delivery rather than preceding it."
            },
            {
              "id": "B",
              "text": "Option B: Observe until spontaneous labor because fetal status is reassuring is inappropriate because maternal deterioration can be rapid despite a reassuring fetus."
            },
            {
              "id": "C",
              "text": "Option D: Perform percutaneous liver biopsy before any obstetric intervention is inappropriate because coagulopathy makes biopsy dangerous, and the clinical syndrome is sufficient to act."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start high-dose corticosteroids and delay delivery until aminotransferases normalize is inappropriate because steroids do not reverse hepatic microvesicular steatosis, and biochemical normalization follows delivery rather than preceding it."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform percutaneous liver biopsy before any obstetric intervention is inappropriate because coagulopathy makes biopsy dangerous, and the clinical syndrome is sufficient to act."
            },
            {
              "id": "B",
              "text": "Option B: Observe until spontaneous labor because fetal status is reassuring is inappropriate because maternal deterioration can be rapid despite a reassuring fetus."
            },
            {
              "id": "C",
              "text": "Option C: Start high-dose corticosteroids and delay delivery until aminotransferases normalize is inappropriate because steroids do not reverse hepatic microvesicular steatosis, and biochemical normalization follows delivery rather than preceding it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform percutaneous liver biopsy before any obstetric intervention is inappropriate because coagulopathy makes biopsy dangerous, and the clinical syndrome is sufficient to act."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with magnesium sulfate alone for presumed severe preeclampsia is inappropriate because magnesium prevents eclamptic seizures but does not treat acute hepatic failure or hypoglycemia."
            },
            {
              "id": "B",
              "text": "Option B: Observe until spontaneous labor because fetal status is reassuring is inappropriate because maternal deterioration can be rapid despite a reassuring fetus."
            },
            {
              "id": "C",
              "text": "Option C: Start high-dose corticosteroids and delay delivery until aminotransferases normalize is inappropriate because steroids do not reverse hepatic microvesicular steatosis, and biochemical normalization follows delivery rather than preceding it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with magnesium sulfate alone for presumed severe preeclampsia is inappropriate because magnesium prevents eclamptic seizures but does not treat acute hepatic failure or hypoglycemia."
        }
      }
    },
    {
      "externalId": "d5-obstetrics-septic-abortion-antibiotics-evacuation-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "b3c9312d4ce8eb144f46c1730ec112cb730f6224f7c946374fd744cd47f43043",
        "ranaze_step3_prd": "b3c9312d4ce8eb144f46c1730ec112cb730f6224f7c946374fd744cd47f43043"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for blood-culture susceptibilities before giving antibiotics or removing retained tissue is inappropriate because culture delay permits rapid progression to shock, DIC, and organ failure."
            },
            {
              "id": "B",
              "text": "Option C: Give oral doxycycline alone and arrange outpatient ultrasonography in one week is inappropriate because shock and retained infected tissue require inpatient IV therapy and procedural source control."
            },
            {
              "id": "C",
              "text": "Option D: Administer additional misoprostol as the only treatment despite septic shock is inappropriate because additional medication does not provide reliable urgent source control in a critically ill patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for blood-culture susceptibilities before giving antibiotics or removing retained tissue is inappropriate because culture delay permits rapid progression to shock, DIC, and organ failure."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give oral doxycycline alone and arrange outpatient ultrasonography in one week is inappropriate because shock and retained infected tissue require inpatient IV therapy and procedural source control."
            },
            {
              "id": "B",
              "text": "Option B: Wait for blood-culture susceptibilities before giving antibiotics or removing retained tissue is inappropriate because culture delay permits rapid progression to shock, DIC, and organ failure."
            },
            {
              "id": "C",
              "text": "Option D: Administer additional misoprostol as the only treatment despite septic shock is inappropriate because additional medication does not provide reliable urgent source control in a critically ill patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give oral doxycycline alone and arrange outpatient ultrasonography in one week is inappropriate because shock and retained infected tissue require inpatient IV therapy and procedural source control."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer additional misoprostol as the only treatment despite septic shock is inappropriate because additional medication does not provide reliable urgent source control in a critically ill patient."
            },
            {
              "id": "B",
              "text": "Option B: Wait for blood-culture susceptibilities before giving antibiotics or removing retained tissue is inappropriate because culture delay permits rapid progression to shock, DIC, and organ failure."
            },
            {
              "id": "C",
              "text": "Option C: Give oral doxycycline alone and arrange outpatient ultrasonography in one week is inappropriate because shock and retained infected tissue require inpatient IV therapy and procedural source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer additional misoprostol as the only treatment despite septic shock is inappropriate because additional medication does not provide reliable urgent source control in a critically ill patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform hysterectomy immediately in every case without attempting uterine evacuation is inappropriate because fertility-preserving evacuation is appropriate unless destructive complications mandate hysterectomy."
            },
            {
              "id": "B",
              "text": "Option B: Wait for blood-culture susceptibilities before giving antibiotics or removing retained tissue is inappropriate because culture delay permits rapid progression to shock, DIC, and organ failure."
            },
            {
              "id": "C",
              "text": "Option C: Give oral doxycycline alone and arrange outpatient ultrasonography in one week is inappropriate because shock and retained infected tissue require inpatient IV therapy and procedural source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform hysterectomy immediately in every case without attempting uterine evacuation is inappropriate because fertility-preserving evacuation is appropriate unless destructive complications mandate hysterectomy."
        }
      }
    },
    {
      "externalId": "d5-obstetrics-tolac-complete-uterine-rupture-emergency-laparotomy-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "411e1ee4fd4d26d9cab9c0b716344abf9ae8a547a1a776df736fd12f7c5d9104",
        "ranaze_step3_prd": "411e1ee4fd4d26d9cab9c0b716344abf9ae8a547a1a776df736fd12f7c5d9104"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop oxytocin and observe for 30 minutes to see whether fetal heart rate recovers is inappropriate because observation wastes critical minutes during ongoing fetal hypoxia and maternal bleeding."
            },
            {
              "id": "B",
              "text": "Option C: Attempt vacuum-assisted vaginal delivery from the now high station is inappropriate because the fetus is no longer safely engaged in the birth canal, making vacuum delivery impossible and dangerous."
            },
            {
              "id": "C",
              "text": "Option D: Obtain CT of the abdomen and pelvis to confirm uterine rupture is inappropriate because uterine rupture is a clinical diagnosis in this unstable setting and CT would delay life-saving surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop oxytocin and observe for 30 minutes to see whether fetal heart rate recovers is inappropriate because observation wastes critical minutes during ongoing fetal hypoxia and maternal bleeding."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Attempt vacuum-assisted vaginal delivery from the now high station is inappropriate because the fetus is no longer safely engaged in the birth canal, making vacuum delivery impossible and dangerous."
            },
            {
              "id": "B",
              "text": "Option B: Stop oxytocin and observe for 30 minutes to see whether fetal heart rate recovers is inappropriate because observation wastes critical minutes during ongoing fetal hypoxia and maternal bleeding."
            },
            {
              "id": "C",
              "text": "Option D: Obtain CT of the abdomen and pelvis to confirm uterine rupture is inappropriate because uterine rupture is a clinical diagnosis in this unstable setting and CT would delay life-saving surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Attempt vacuum-assisted vaginal delivery from the now high station is inappropriate because the fetus is no longer safely engaged in the birth canal, making vacuum delivery impossible and dangerous."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain CT of the abdomen and pelvis to confirm uterine rupture is inappropriate because uterine rupture is a clinical diagnosis in this unstable setting and CT would delay life-saving surgery."
            },
            {
              "id": "B",
              "text": "Option B: Stop oxytocin and observe for 30 minutes to see whether fetal heart rate recovers is inappropriate because observation wastes critical minutes during ongoing fetal hypoxia and maternal bleeding."
            },
            {
              "id": "C",
              "text": "Option C: Attempt vacuum-assisted vaginal delivery from the now high station is inappropriate because the fetus is no longer safely engaged in the birth canal, making vacuum delivery impossible and dangerous."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain CT of the abdomen and pelvis to confirm uterine rupture is inappropriate because uterine rupture is a clinical diagnosis in this unstable setting and CT would delay life-saving surgery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer terbutaline and resume labor after contractions diminish is inappropriate because tocolysis cannot close a full-thickness tear or treat hemoperitoneum."
            },
            {
              "id": "B",
              "text": "Option B: Stop oxytocin and observe for 30 minutes to see whether fetal heart rate recovers is inappropriate because observation wastes critical minutes during ongoing fetal hypoxia and maternal bleeding."
            },
            {
              "id": "C",
              "text": "Option C: Attempt vacuum-assisted vaginal delivery from the now high station is inappropriate because the fetus is no longer safely engaged in the birth canal, making vacuum delivery impossible and dangerous."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer terbutaline and resume labor after contractions diminish is inappropriate because tocolysis cannot close a full-thickness tear or treat hemoperitoneum."
        }
      }
    },
    {
      "externalId": "d5-oncology-car-t-grade2-crs-tocilizumab-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "90c90faa229d9bfdb181dd1de894f29f919bb8ccb9989c976a4e3638207b3e04",
        "ranaze_step3_prd": "90c90faa229d9bfdb181dd1de894f29f919bb8ccb9989c976a4e3638207b3e04"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diphenhydramine alone is inappropriate because antihistamine does not reverse cytokine-mediated shock."
            },
            {
              "id": "B",
              "text": "Option C: High-dose methotrexate rescue is inappropriate because methotrexate rescue treats antifolate toxicity, not CRS."
            },
            {
              "id": "C",
              "text": "Option D: Plasma exchange is not standard CAR-T CRS treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diphenhydramine alone is inappropriate because antihistamine does not reverse cytokine-mediated shock."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose methotrexate rescue is inappropriate because methotrexate rescue treats antifolate toxicity, not CRS."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine alone is inappropriate because antihistamine does not reverse cytokine-mediated shock."
            },
            {
              "id": "C",
              "text": "Option D: Plasma exchange is not standard CAR-T CRS treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose methotrexate rescue is inappropriate because methotrexate rescue treats antifolate toxicity, not CRS."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plasma exchange is not standard CAR-T CRS treatment."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine alone is inappropriate because antihistamine does not reverse cytokine-mediated shock."
            },
            {
              "id": "C",
              "text": "Option C: High-dose methotrexate rescue is inappropriate because methotrexate rescue treats antifolate toxicity, not CRS."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plasma exchange is not standard CAR-T CRS treatment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation without immunomodulation until multiorgan failure develops is inappropriate because delaying treatment risks rapid progression to severe organ injury."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine alone is inappropriate because antihistamine does not reverse cytokine-mediated shock."
            },
            {
              "id": "C",
              "text": "Option C: High-dose methotrexate rescue is inappropriate because methotrexate rescue treats antifolate toxicity, not CRS."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation without immunomodulation until multiorgan failure develops is inappropriate because delaying treatment risks rapid progression to severe organ injury."
        }
      }
    },
    {
      "externalId": "d5-oncology-car-t-icans-steroids-not-tocilizumab-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "7ed5d490623e43f524911f8916acf147912707e88f76537d21119f3ea9fcc77c",
        "ranaze_step3_prd": "7ed5d490623e43f524911f8916acf147912707e88f76537d21119f3ea9fcc77c"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat tocilizumab as sole therapy despite no concurrent CRS is inappropriate because repeat IL-6 blockade alone is ineffective without concurrent CRS."
            },
            {
              "id": "B",
              "text": "Option C: Give haloperidol and discharge after the seizure stops is inappropriate because sedation and discharge are unsafe after CAR-T neurotoxicity and seizure."
            },
            {
              "id": "C",
              "text": "Option D: Administer alteplase for presumed ischemic stroke is inappropriate because the diffuse syndrome and timing are not a thrombolysis indication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat tocilizumab as sole therapy despite no concurrent CRS is inappropriate because repeat IL-6 blockade alone is ineffective without concurrent CRS."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give haloperidol and discharge after the seizure stops is inappropriate because sedation and discharge are unsafe after CAR-T neurotoxicity and seizure."
            },
            {
              "id": "B",
              "text": "Option A: Repeat tocilizumab as sole therapy despite no concurrent CRS is inappropriate because repeat IL-6 blockade alone is ineffective without concurrent CRS."
            },
            {
              "id": "C",
              "text": "Option D: Administer alteplase for presumed ischemic stroke is inappropriate because the diffuse syndrome and timing are not a thrombolysis indication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give haloperidol and discharge after the seizure stops is inappropriate because sedation and discharge are unsafe after CAR-T neurotoxicity and seizure."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer alteplase for presumed ischemic stroke is inappropriate because the diffuse syndrome and timing are not a thrombolysis indication."
            },
            {
              "id": "B",
              "text": "Option A: Repeat tocilizumab as sole therapy despite no concurrent CRS is inappropriate because repeat IL-6 blockade alone is ineffective without concurrent CRS."
            },
            {
              "id": "C",
              "text": "Option C: Give haloperidol and discharge after the seizure stops is inappropriate because sedation and discharge are unsafe after CAR-T neurotoxicity and seizure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer alteplase for presumed ischemic stroke is inappropriate because the diffuse syndrome and timing are not a thrombolysis indication."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restart CAR-T infusion at a slower rate is inappropriate because cAR-T cells are a single therapeutic infusion, not restarted like an antibiotic drip."
            },
            {
              "id": "B",
              "text": "Option A: Repeat tocilizumab as sole therapy despite no concurrent CRS is inappropriate because repeat IL-6 blockade alone is ineffective without concurrent CRS."
            },
            {
              "id": "C",
              "text": "Option C: Give haloperidol and discharge after the seizure stops is inappropriate because sedation and discharge are unsafe after CAR-T neurotoxicity and seizure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restart CAR-T infusion at a slower rate is inappropriate because cAR-T cells are a single therapeutic infusion, not restarted like an antibiotic drip."
        }
      }
    },
    {
      "externalId": "d5-oncology-checkpoint-myocarditis-overlap-pulse-steroids-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "3c89eb1807ed098acc6c63396e2c84f0d6d1800f89b5e3e22ef726fc3045e369",
        "ranaze_step3_prd": "3c89eb1807ed098acc6c63396e2c84f0d6d1800f89b5e3e22ef726fc3045e369"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue checkpoint therapy and repeat troponin in one week is inappropriate because delay can be fatal and continued ICI worsens immune injury."
            },
            {
              "id": "B",
              "text": "Option C: Administer infliximab as the preferred first-line monotherapy is inappropriate because infliximab is not first-line and can worsen heart failure."
            },
            {
              "id": "C",
              "text": "Option D: Treat with pyridostigmine alone and discharge is inappropriate because pyridostigmine does not treat myocardial and skeletal-muscle immune inflammation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue checkpoint therapy and repeat troponin in one week is inappropriate because delay can be fatal and continued ICI worsens immune injury."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer infliximab as the preferred first-line monotherapy is inappropriate because infliximab is not first-line and can worsen heart failure."
            },
            {
              "id": "B",
              "text": "Option A: Continue checkpoint therapy and repeat troponin in one week is inappropriate because delay can be fatal and continued ICI worsens immune injury."
            },
            {
              "id": "C",
              "text": "Option D: Treat with pyridostigmine alone and discharge is inappropriate because pyridostigmine does not treat myocardial and skeletal-muscle immune inflammation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer infliximab as the preferred first-line monotherapy is inappropriate because infliximab is not first-line and can worsen heart failure."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with pyridostigmine alone and discharge is inappropriate because pyridostigmine does not treat myocardial and skeletal-muscle immune inflammation."
            },
            {
              "id": "B",
              "text": "Option A: Continue checkpoint therapy and repeat troponin in one week is inappropriate because delay can be fatal and continued ICI worsens immune injury."
            },
            {
              "id": "C",
              "text": "Option C: Administer infliximab as the preferred first-line monotherapy is inappropriate because infliximab is not first-line and can worsen heart failure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with pyridostigmine alone and discharge is inappropriate because pyridostigmine does not treat myocardial and skeletal-muscle immune inflammation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give thrombolytic therapy for presumed coronary thrombosis is inappropriate because normal coronaries and the overlap phenotype argue against thrombotic infarction."
            },
            {
              "id": "B",
              "text": "Option A: Continue checkpoint therapy and repeat troponin in one week is inappropriate because delay can be fatal and continued ICI worsens immune injury."
            },
            {
              "id": "C",
              "text": "Option C: Administer infliximab as the preferred first-line monotherapy is inappropriate because infliximab is not first-line and can worsen heart failure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give thrombolytic therapy for presumed coronary thrombosis is inappropriate because normal coronaries and the overlap phenotype argue against thrombotic infarction."
        }
      }
    },
    {
      "externalId": "d5-pediatrics-acute-bilirubin-encephalopathy-exchange-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "8e0d7ba6fe7e2da4f0f3f94feb681a855ad72a7afbc0e05b37ef2b4c754b8b12",
        "ranaze_step3_prd": "8e0d7ba6fe7e2da4f0f3f94feb681a855ad72a7afbc0e05b37ef2b4c754b8b12"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue phototherapy alone and defer further treatment until the repeat bilirubin is available is inappropriate because phototherapy alone is inadequate in symptomatic neurotoxicity above the exchange threshold."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous immune globulin before determining whether hemolysis is present is inappropriate because iVIG is not routine and does not replace exchange transfusion in acute bilirubin encephalopathy."
            },
            {
              "id": "C",
              "text": "Option D: Stop phototherapy because light exposure can worsen acute bilirubin encephalopathy is inappropriate because intensive phototherapy should continue while exchange blood is prepared."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue phototherapy alone and defer further treatment until the repeat bilirubin is available is inappropriate because phototherapy alone is inadequate in symptomatic neurotoxicity above the exchange threshold."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous immune globulin before determining whether hemolysis is present is inappropriate because iVIG is not routine and does not replace exchange transfusion in acute bilirubin encephalopathy."
            },
            {
              "id": "B",
              "text": "Option A: Continue phototherapy alone and defer further treatment until the repeat bilirubin is available is inappropriate because phototherapy alone is inadequate in symptomatic neurotoxicity above the exchange threshold."
            },
            {
              "id": "C",
              "text": "Option D: Stop phototherapy because light exposure can worsen acute bilirubin encephalopathy is inappropriate because intensive phototherapy should continue while exchange blood is prepared."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous immune globulin before determining whether hemolysis is present is inappropriate because iVIG is not routine and does not replace exchange transfusion in acute bilirubin encephalopathy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop phototherapy because light exposure can worsen acute bilirubin encephalopathy is inappropriate because intensive phototherapy should continue while exchange blood is prepared."
            },
            {
              "id": "B",
              "text": "Option A: Continue phototherapy alone and defer further treatment until the repeat bilirubin is available is inappropriate because phototherapy alone is inadequate in symptomatic neurotoxicity above the exchange threshold."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous immune globulin before determining whether hemolysis is present is inappropriate because iVIG is not routine and does not replace exchange transfusion in acute bilirubin encephalopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop phototherapy because light exposure can worsen acute bilirubin encephalopathy is inappropriate because intensive phototherapy should continue while exchange blood is prepared."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule outpatient auditory brainstem response testing and repeat bilirubin tomorrow is inappropriate because outpatient reassessment is unsafe in an infant with an acute neurologic emergency."
            },
            {
              "id": "B",
              "text": "Option A: Continue phototherapy alone and defer further treatment until the repeat bilirubin is available is inappropriate because phototherapy alone is inadequate in symptomatic neurotoxicity above the exchange threshold."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous immune globulin before determining whether hemolysis is present is inappropriate because iVIG is not routine and does not replace exchange transfusion in acute bilirubin encephalopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule outpatient auditory brainstem response testing and repeat bilirubin tomorrow is inappropriate because outpatient reassessment is unsafe in an infant with an acute neurologic emergency."
        }
      }
    },
    {
      "externalId": "d5-pediatrics-midgut-volvulus-peritonitis-operation-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "c0c852aafb165ff6cb8775d3d8a098a933228cf08d182e61afcbeb7334ea6c33",
        "ranaze_step3_prd": "c0c852aafb165ff6cb8775d3d8a098a933228cf08d182e61afcbeb7334ea6c33"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an upper gastrointestinal contrast series before consulting or proceeding with surgery is inappropriate because upper GI imaging is appropriate when stable, but here it would delay treatment of threatened bowel."
            },
            {
              "id": "B",
              "text": "Option C: Obtain an air-contrast enema to reduce presumed ileocolic intussusception is inappropriate because enema reduction treats intussusception, not neonatal midgut volvulus with shock."
            },
            {
              "id": "C",
              "text": "Option D: Observe with serial abdominal examinations after nasogastric decompression is inappropriate because observation risks rapid progression to total midgut necrosis and death."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an upper gastrointestinal contrast series before consulting or proceeding with surgery is inappropriate because upper GI imaging is appropriate when stable, but here it would delay treatment of threatened bowel."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an air-contrast enema to reduce presumed ileocolic intussusception is inappropriate because enema reduction treats intussusception, not neonatal midgut volvulus with shock."
            },
            {
              "id": "B",
              "text": "Option A: Obtain an upper gastrointestinal contrast series before consulting or proceeding with surgery is inappropriate because upper GI imaging is appropriate when stable, but here it would delay treatment of threatened bowel."
            },
            {
              "id": "C",
              "text": "Option D: Observe with serial abdominal examinations after nasogastric decompression is inappropriate because observation risks rapid progression to total midgut necrosis and death."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an air-contrast enema to reduce presumed ileocolic intussusception is inappropriate because enema reduction treats intussusception, not neonatal midgut volvulus with shock."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe with serial abdominal examinations after nasogastric decompression is inappropriate because observation risks rapid progression to total midgut necrosis and death."
            },
            {
              "id": "B",
              "text": "Option A: Obtain an upper gastrointestinal contrast series before consulting or proceeding with surgery is inappropriate because upper GI imaging is appropriate when stable, but here it would delay treatment of threatened bowel."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an air-contrast enema to reduce presumed ileocolic intussusception is inappropriate because enema reduction treats intussusception, not neonatal midgut volvulus with shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe with serial abdominal examinations after nasogastric decompression is inappropriate because observation risks rapid progression to total midgut necrosis and death."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin a proton pump inhibitor for presumed neonatal reflux is inappropriate because bilious emesis is not physiologic reflux and guarding indicates a surgical abdomen."
            },
            {
              "id": "B",
              "text": "Option A: Obtain an upper gastrointestinal contrast series before consulting or proceeding with surgery is inappropriate because upper GI imaging is appropriate when stable, but here it would delay treatment of threatened bowel."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an air-contrast enema to reduce presumed ileocolic intussusception is inappropriate because enema reduction treats intussusception, not neonatal midgut volvulus with shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin a proton pump inhibitor for presumed neonatal reflux is inappropriate because bilious emesis is not physiologic reflux and guarding indicates a surgical abdomen."
        }
      }
    },
    {
      "externalId": "d5-pediatrics-tetralogy-hypercyanotic-spell-sequence-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "66cefe4c0216cebca15218b601817d68ea629834b1ac3a5b4f099a0f24c80927",
        "ranaze_step3_prd": "66cefe4c0216cebca15218b601817d68ea629834b1ac3a5b4f099a0f24c80927"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place him supine with the legs extended and administer intravenous furosemide is inappropriate because leg extension and diuresis reduce preload and may aggravate right-to-left shunting."
            },
            {
              "id": "B",
              "text": "Option C: Administer inhaled albuterol and chest physiotherapy is inappropriate because bronchospasm does not explain the softer murmur and profound cyanosis in unrepaired tetralogy."
            },
            {
              "id": "C",
              "text": "Option D: Begin prostaglandin E1 solely to reopen the ductus arteriosus in this 8-month-old is inappropriate because at this age, the ductus is not expected to be pharmacologically recruitable as the primary rescue strategy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place him supine with the legs extended and administer intravenous furosemide is inappropriate because leg extension and diuresis reduce preload and may aggravate right-to-left shunting."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer inhaled albuterol and chest physiotherapy is inappropriate because bronchospasm does not explain the softer murmur and profound cyanosis in unrepaired tetralogy."
            },
            {
              "id": "B",
              "text": "Option A: Place him supine with the legs extended and administer intravenous furosemide is inappropriate because leg extension and diuresis reduce preload and may aggravate right-to-left shunting."
            },
            {
              "id": "C",
              "text": "Option D: Begin prostaglandin E1 solely to reopen the ductus arteriosus in this 8-month-old is inappropriate because at this age, the ductus is not expected to be pharmacologically recruitable as the primary rescue strategy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer inhaled albuterol and chest physiotherapy is inappropriate because bronchospasm does not explain the softer murmur and profound cyanosis in unrepaired tetralogy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin prostaglandin E1 solely to reopen the ductus arteriosus in this 8-month-old is inappropriate because at this age, the ductus is not expected to be pharmacologically recruitable as the primary rescue strategy."
            },
            {
              "id": "B",
              "text": "Option A: Place him supine with the legs extended and administer intravenous furosemide is inappropriate because leg extension and diuresis reduce preload and may aggravate right-to-left shunting."
            },
            {
              "id": "C",
              "text": "Option C: Administer inhaled albuterol and chest physiotherapy is inappropriate because bronchospasm does not explain the softer murmur and profound cyanosis in unrepaired tetralogy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin prostaglandin E1 solely to reopen the ductus arteriosus in this 8-month-old is inappropriate because at this age, the ductus is not expected to be pharmacologically recruitable as the primary rescue strategy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform synchronized cardioversion for presumed supraventricular tachycardia is inappropriate because the presentation is hemodynamic shunting rather than an unstable tachyarrhythmia."
            },
            {
              "id": "B",
              "text": "Option A: Place him supine with the legs extended and administer intravenous furosemide is inappropriate because leg extension and diuresis reduce preload and may aggravate right-to-left shunting."
            },
            {
              "id": "C",
              "text": "Option C: Administer inhaled albuterol and chest physiotherapy is inappropriate because bronchospasm does not explain the softer murmur and profound cyanosis in unrepaired tetralogy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform synchronized cardioversion for presumed supraventricular tachycardia is inappropriate because the presentation is hemodynamic shunting rather than an unstable tachyarrhythmia."
        }
      }
    },
    {
      "externalId": "d5-psychiatry-clozapine-myocarditis-stop-evaluate-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "dab575d891887638d2fcf4c64e0e91f912cee2b0c28d4db7f70d7341fdcd437b",
        "ranaze_step3_prd": "dab575d891887638d2fcf4c64e0e91f912cee2b0c28d4db7f70d7341fdcd437b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue clozapine because the absolute neutrophil count is normal is inappropriate because normal neutrophils do not exclude a different life-threatening boxed adverse effect."
            },
            {
              "id": "B",
              "text": "Option B: Reduce clozapine by 25 mg and repeat troponin in one month is inappropriate because dose reduction and delayed reassessment are unsafe with suspected myocarditis."
            },
            {
              "id": "C",
              "text": "Option D: Administer benztropine and continue the current clozapine dose is inappropriate because benztropine has no role in myocarditis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue clozapine because the absolute neutrophil count is normal is inappropriate because normal neutrophils do not exclude a different life-threatening boxed adverse effect."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduce clozapine by 25 mg and repeat troponin in one month is inappropriate because dose reduction and delayed reassessment are unsafe with suspected myocarditis."
            },
            {
              "id": "B",
              "text": "Option A: Continue clozapine because the absolute neutrophil count is normal is inappropriate because normal neutrophils do not exclude a different life-threatening boxed adverse effect."
            },
            {
              "id": "C",
              "text": "Option D: Administer benztropine and continue the current clozapine dose is inappropriate because benztropine has no role in myocarditis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduce clozapine by 25 mg and repeat troponin in one month is inappropriate because dose reduction and delayed reassessment are unsafe with suspected myocarditis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer benztropine and continue the current clozapine dose is inappropriate because benztropine has no role in myocarditis."
            },
            {
              "id": "B",
              "text": "Option A: Continue clozapine because the absolute neutrophil count is normal is inappropriate because normal neutrophils do not exclude a different life-threatening boxed adverse effect."
            },
            {
              "id": "C",
              "text": "Option B: Reduce clozapine by 25 mg and repeat troponin in one month is inappropriate because dose reduction and delayed reassessment are unsafe with suspected myocarditis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer benztropine and continue the current clozapine dose is inappropriate because benztropine has no role in myocarditis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Switch temporarily to lithium while continuing clozapine is inappropriate because lithium does not neutralize ongoing clozapine cardiac toxicity."
            },
            {
              "id": "B",
              "text": "Option A: Continue clozapine because the absolute neutrophil count is normal is inappropriate because normal neutrophils do not exclude a different life-threatening boxed adverse effect."
            },
            {
              "id": "C",
              "text": "Option B: Reduce clozapine by 25 mg and repeat troponin in one month is inappropriate because dose reduction and delayed reassessment are unsafe with suspected myocarditis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Switch temporarily to lithium while continuing clozapine is inappropriate because lithium does not neutralize ongoing clozapine cardiac toxicity."
        }
      }
    },
    {
      "externalId": "d5-psychiatry-postpartum-psychosis-inpatient-safety-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "051b06e84bacb9da69574ec98fd94306a1c3aceac8ff2b22bc34a198f25713ed",
        "ranaze_step3_prd": "051b06e84bacb9da69574ec98fd94306a1c3aceac8ff2b22bc34a198f25713ed"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassure the family that transient postpartum mood symptoms resolve without treatment is inappropriate because psychosis is not a normal postpartum mood fluctuation."
            },
            {
              "id": "B",
              "text": "Option B: Arrange weekly outpatient psychotherapy while allowing her to remain the sole caregiver is inappropriate because outpatient care cannot safely contain imminent infant-directed risk."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe an SSRI alone and discharge her home is inappropriate because an SSRI alone is inadequate and can aggravate mania."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassure the family that transient postpartum mood symptoms resolve without treatment is inappropriate because psychosis is not a normal postpartum mood fluctuation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange weekly outpatient psychotherapy while allowing her to remain the sole caregiver is inappropriate because outpatient care cannot safely contain imminent infant-directed risk."
            },
            {
              "id": "B",
              "text": "Option A: Reassure the family that transient postpartum mood symptoms resolve without treatment is inappropriate because psychosis is not a normal postpartum mood fluctuation."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe an SSRI alone and discharge her home is inappropriate because an SSRI alone is inadequate and can aggravate mania."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange weekly outpatient psychotherapy while allowing her to remain the sole caregiver is inappropriate because outpatient care cannot safely contain imminent infant-directed risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe an SSRI alone and discharge her home is inappropriate because an SSRI alone is inadequate and can aggravate mania."
            },
            {
              "id": "B",
              "text": "Option A: Reassure the family that transient postpartum mood symptoms resolve without treatment is inappropriate because psychosis is not a normal postpartum mood fluctuation."
            },
            {
              "id": "C",
              "text": "Option B: Arrange weekly outpatient psychotherapy while allowing her to remain the sole caregiver is inappropriate because outpatient care cannot safely contain imminent infant-directed risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe an SSRI alone and discharge her home is inappropriate because an SSRI alone is inadequate and can aggravate mania."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the spouse to obtain a court custody order before clinicians intervene is inappropriate because emergency clinicians need not wait for family court action to prevent imminent harm."
            },
            {
              "id": "B",
              "text": "Option A: Reassure the family that transient postpartum mood symptoms resolve without treatment is inappropriate because psychosis is not a normal postpartum mood fluctuation."
            },
            {
              "id": "C",
              "text": "Option B: Arrange weekly outpatient psychotherapy while allowing her to remain the sole caregiver is inappropriate because outpatient care cannot safely contain imminent infant-directed risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the spouse to obtain a court custody order before clinicians intervene is inappropriate because emergency clinicians need not wait for family court action to prevent imminent harm."
        }
      }
    },
    {
      "externalId": "d5-psychiatry-valproate-hyperammonemic-encephalopathy-carnitine-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "2dfcdf60f2df376c269d202f4b7357b1d993a60b874a824dc239082d82f17a10",
        "ranaze_step3_prd": "2dfcdf60f2df376c269d202f4b7357b1d993a60b874a824dc239082d82f17a10"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue valproate because the serum concentration is therapeutic and give lactulose alone is inappropriate because a therapeutic total level does not rule out valproate toxicity."
            },
            {
              "id": "B",
              "text": "Option C: Increase topiramate to prevent seizures during the episode is inappropriate because topiramate can potentiate the syndrome and should not be increased."
            },
            {
              "id": "C",
              "text": "Option D: Administer flumazenil is inappropriate because flumazenil reverses benzodiazepines, not valproate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue valproate because the serum concentration is therapeutic and give lactulose alone is inappropriate because a therapeutic total level does not rule out valproate toxicity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase topiramate to prevent seizures during the episode is inappropriate because topiramate can potentiate the syndrome and should not be increased."
            },
            {
              "id": "B",
              "text": "Option A: Continue valproate because the serum concentration is therapeutic and give lactulose alone is inappropriate because a therapeutic total level does not rule out valproate toxicity."
            },
            {
              "id": "C",
              "text": "Option D: Administer flumazenil is inappropriate because flumazenil reverses benzodiazepines, not valproate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase topiramate to prevent seizures during the episode is inappropriate because topiramate can potentiate the syndrome and should not be increased."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer flumazenil is inappropriate because flumazenil reverses benzodiazepines, not valproate."
            },
            {
              "id": "B",
              "text": "Option A: Continue valproate because the serum concentration is therapeutic and give lactulose alone is inappropriate because a therapeutic total level does not rule out valproate toxicity."
            },
            {
              "id": "C",
              "text": "Option C: Increase topiramate to prevent seizures during the episode is inappropriate because topiramate can potentiate the syndrome and should not be increased."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer flumazenil is inappropriate because flumazenil reverses benzodiazepines, not valproate."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin emergent hemodialysis solely because the ammonia is elevated is inappropriate because dialysis is for severe systemic poisoning criteria, not ammonia elevation alone in a stable patient."
            },
            {
              "id": "B",
              "text": "Option A: Continue valproate because the serum concentration is therapeutic and give lactulose alone is inappropriate because a therapeutic total level does not rule out valproate toxicity."
            },
            {
              "id": "C",
              "text": "Option C: Increase topiramate to prevent seizures during the episode is inappropriate because topiramate can potentiate the syndrome and should not be increased."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin emergent hemodialysis solely because the ammonia is elevated is inappropriate because dialysis is for severe systemic poisoning criteria, not ammonia elevation alone in a stable patient."
        }
      }
    },
    {
      "externalId": "d5-pulmonary-bronchopleural-fistula-ventilator-strategy-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "6aec995486f7f3422cf44c36ca1c6c74dae03614e27ec3817f6fff30679c0d93",
        "ranaze_step3_prd": "6aec995486f7f3422cf44c36ca1c6c74dae03614e27ec3817f6fff30679c0d93"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase PEEP to 20 cm H2O to force the affected lung to remain expanded is inappropriate because high PEEP increases fistula flow and can enlarge the defect."
            },
            {
              "id": "B",
              "text": "Option C: Clamp the chest tube to prevent loss of delivered tidal volume is inappropriate because clamping a tube in a patient with an ongoing airway-pleural communication risks tension pneumothorax."
            },
            {
              "id": "C",
              "text": "Option D: Increase tidal volume and inspiratory time until exhaled volume equals the set volume is inappropriate because higher tidal volume and longer inspiratory time raise mean airway pressure and worsen the leak."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase PEEP to 20 cm H2O to force the affected lung to remain expanded is inappropriate because high PEEP increases fistula flow and can enlarge the defect."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Clamp the chest tube to prevent loss of delivered tidal volume is inappropriate because clamping a tube in a patient with an ongoing airway-pleural communication risks tension pneumothorax."
            },
            {
              "id": "B",
              "text": "Option B: Increase PEEP to 20 cm H2O to force the affected lung to remain expanded is inappropriate because high PEEP increases fistula flow and can enlarge the defect."
            },
            {
              "id": "C",
              "text": "Option D: Increase tidal volume and inspiratory time until exhaled volume equals the set volume is inappropriate because higher tidal volume and longer inspiratory time raise mean airway pressure and worsen the leak."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Clamp the chest tube to prevent loss of delivered tidal volume is inappropriate because clamping a tube in a patient with an ongoing airway-pleural communication risks tension pneumothorax."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase tidal volume and inspiratory time until exhaled volume equals the set volume is inappropriate because higher tidal volume and longer inspiratory time raise mean airway pressure and worsen the leak."
            },
            {
              "id": "B",
              "text": "Option B: Increase PEEP to 20 cm H2O to force the affected lung to remain expanded is inappropriate because high PEEP increases fistula flow and can enlarge the defect."
            },
            {
              "id": "C",
              "text": "Option C: Clamp the chest tube to prevent loss of delivered tidal volume is inappropriate because clamping a tube in a patient with an ongoing airway-pleural communication risks tension pneumothorax."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase tidal volume and inspiratory time until exhaled volume equals the set volume is inappropriate because higher tidal volume and longer inspiratory time raise mean airway pressure and worsen the leak."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remove the endotracheal tube immediately regardless of gas exchange is inappropriate because extubation is appropriate only if the patient can safely maintain ventilation and oxygenation without invasive support."
            },
            {
              "id": "B",
              "text": "Option B: Increase PEEP to 20 cm H2O to force the affected lung to remain expanded is inappropriate because high PEEP increases fistula flow and can enlarge the defect."
            },
            {
              "id": "C",
              "text": "Option C: Clamp the chest tube to prevent loss of delivered tidal volume is inappropriate because clamping a tube in a patient with an ongoing airway-pleural communication risks tension pneumothorax."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remove the endotracheal tube immediately regardless of gas exchange is inappropriate because extubation is appropriate only if the patient can safely maintain ventilation and oxygenation without invasive support."
        }
      }
    },
    {
      "externalId": "d5-pulmonary-refractory-ards-vv-ecmo-selection-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "0b902020905946778817b7342e49aef912b2b440f979314bbda593c110de6479",
        "ranaze_step3_prd": "0b902020905946778817b7342e49aef912b2b440f979314bbda593c110de6479"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase plateau pressure above 40 cm H2O until PaO2 normalizes is inappropriate because excess plateau pressure worsens barotrauma and volutrauma instead of safely supporting gas exchange."
            },
            {
              "id": "B",
              "text": "Option C: Switch to venoarterial extracorporeal membrane oxygenation because all ECMO provides cardiac support is inappropriate because preserved cardiac function makes venovenous, not venoarterial, support appropriate."
            },
            {
              "id": "C",
              "text": "Option D: Continue the same therapy for another week before considering extracorporeal support is inappropriate because prolonged injurious ventilation and delayed cannulation are associated with poorer ECMO outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase plateau pressure above 40 cm H2O until PaO2 normalizes is inappropriate because excess plateau pressure worsens barotrauma and volutrauma instead of safely supporting gas exchange."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Switch to venoarterial extracorporeal membrane oxygenation because all ECMO provides cardiac support is inappropriate because preserved cardiac function makes venovenous, not venoarterial, support appropriate."
            },
            {
              "id": "B",
              "text": "Option B: Increase plateau pressure above 40 cm H2O until PaO2 normalizes is inappropriate because excess plateau pressure worsens barotrauma and volutrauma instead of safely supporting gas exchange."
            },
            {
              "id": "C",
              "text": "Option D: Continue the same therapy for another week before considering extracorporeal support is inappropriate because prolonged injurious ventilation and delayed cannulation are associated with poorer ECMO outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Switch to venoarterial extracorporeal membrane oxygenation because all ECMO provides cardiac support is inappropriate because preserved cardiac function makes venovenous, not venoarterial, support appropriate."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue the same therapy for another week before considering extracorporeal support is inappropriate because prolonged injurious ventilation and delayed cannulation are associated with poorer ECMO outcomes."
            },
            {
              "id": "B",
              "text": "Option B: Increase plateau pressure above 40 cm H2O until PaO2 normalizes is inappropriate because excess plateau pressure worsens barotrauma and volutrauma instead of safely supporting gas exchange."
            },
            {
              "id": "C",
              "text": "Option C: Switch to venoarterial extracorporeal membrane oxygenation because all ECMO provides cardiac support is inappropriate because preserved cardiac function makes venovenous, not venoarterial, support appropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue the same therapy for another week before considering extracorporeal support is inappropriate because prolonged injurious ventilation and delayed cannulation are associated with poorer ECMO outcomes."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer sodium bicarbonate as definitive treatment of the respiratory acidosis is inappropriate because bicarbonate can increase CO2 load and does not resolve refractory ventilatory failure."
            },
            {
              "id": "B",
              "text": "Option B: Increase plateau pressure above 40 cm H2O until PaO2 normalizes is inappropriate because excess plateau pressure worsens barotrauma and volutrauma instead of safely supporting gas exchange."
            },
            {
              "id": "C",
              "text": "Option C: Switch to venoarterial extracorporeal membrane oxygenation because all ECMO provides cardiac support is inappropriate because preserved cardiac function makes venovenous, not venoarterial, support appropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer sodium bicarbonate as definitive treatment of the respiratory acidosis is inappropriate because bicarbonate can increase CO2 load and does not resolve refractory ventilatory failure."
        }
      }
    },
    {
      "externalId": "d5-pulmonary-severe-ards-early-prone-positioning-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "4bcb83116f2d6d9bd7ce7bcba109822d31b7fc3aee2e9d53237fa3183e0591e7",
        "ranaze_step3_prd": "4bcb83116f2d6d9bd7ce7bcba109822d31b7fc3aee2e9d53237fa3183e0591e7"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase tidal volume to 10 mL/kg to recruit dependent lung is inappropriate because increasing tidal volume causes volutrauma and negates the established lung-protective strategy."
            },
            {
              "id": "B",
              "text": "Option C: Perform a prolonged high-pressure recruitment maneuver is inappropriate because prolonged high-pressure recruitment maneuvers increase harm in moderate-to-severe ARDS."
            },
            {
              "id": "C",
              "text": "Option D: Begin inhaled nitric oxide as routine definitive therapy is inappropriate because inhaled nitric oxide is a transient rescue measure, not routine mortality-improving definitive therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase tidal volume to 10 mL/kg to recruit dependent lung is inappropriate because increasing tidal volume causes volutrauma and negates the established lung-protective strategy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a prolonged high-pressure recruitment maneuver is inappropriate because prolonged high-pressure recruitment maneuvers increase harm in moderate-to-severe ARDS."
            },
            {
              "id": "B",
              "text": "Option B: Increase tidal volume to 10 mL/kg to recruit dependent lung is inappropriate because increasing tidal volume causes volutrauma and negates the established lung-protective strategy."
            },
            {
              "id": "C",
              "text": "Option D: Begin inhaled nitric oxide as routine definitive therapy is inappropriate because inhaled nitric oxide is a transient rescue measure, not routine mortality-improving definitive therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a prolonged high-pressure recruitment maneuver is inappropriate because prolonged high-pressure recruitment maneuvers increase harm in moderate-to-severe ARDS."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin inhaled nitric oxide as routine definitive therapy is inappropriate because inhaled nitric oxide is a transient rescue measure, not routine mortality-improving definitive therapy."
            },
            {
              "id": "B",
              "text": "Option B: Increase tidal volume to 10 mL/kg to recruit dependent lung is inappropriate because increasing tidal volume causes volutrauma and negates the established lung-protective strategy."
            },
            {
              "id": "C",
              "text": "Option C: Perform a prolonged high-pressure recruitment maneuver is inappropriate because prolonged high-pressure recruitment maneuvers increase harm in moderate-to-severe ARDS."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin inhaled nitric oxide as routine definitive therapy is inappropriate because inhaled nitric oxide is a transient rescue measure, not routine mortality-improving definitive therapy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Initiate venovenous extracorporeal membrane oxygenation before a prone-positioning trial is inappropriate because a prone trial is part of optimized conventional treatment before VV-ECMO when no contraindication exists."
            },
            {
              "id": "B",
              "text": "Option B: Increase tidal volume to 10 mL/kg to recruit dependent lung is inappropriate because increasing tidal volume causes volutrauma and negates the established lung-protective strategy."
            },
            {
              "id": "C",
              "text": "Option C: Perform a prolonged high-pressure recruitment maneuver is inappropriate because prolonged high-pressure recruitment maneuvers increase harm in moderate-to-severe ARDS."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Initiate venovenous extracorporeal membrane oxygenation before a prone-positioning trial is inappropriate because a prone trial is part of optimized conventional treatment before VV-ECMO when no contraindication exists."
        }
      }
    },
    {
      "externalId": "d5-renal-hyponatremia-overcorrection-ddavp-d5w-relowering-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "dc10cfe27e206c9679d0f6f012b13377f2119fd8248bc65d3a388f42bff0695b",
        "ranaze_step3_prd": "dc10cfe27e206c9679d0f6f012b13377f2119fd8248bc65d3a388f42bff0695b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue allowing sodium to rise because seizure resolution eliminates osmotic demyelination risk is inappropriate because osmotic demyelination is delayed and risk persists despite immediate clinical improvement."
            },
            {
              "id": "B",
              "text": "Option C: Give additional hypertonic saline until sodium reaches 140 mEq/L today is inappropriate because further hypertonic saline would magnify an already unsafe correction."
            },
            {
              "id": "C",
              "text": "Option D: Start a vasopressin-receptor antagonist to accelerate free-water excretion is inappropriate because a vaptan increases free-water loss and would accelerate the sodium rise."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue allowing sodium to rise because seizure resolution eliminates osmotic demyelination risk is inappropriate because osmotic demyelination is delayed and risk persists despite immediate clinical improvement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give additional hypertonic saline until sodium reaches 140 mEq/L today is inappropriate because further hypertonic saline would magnify an already unsafe correction."
            },
            {
              "id": "B",
              "text": "Option B: Continue allowing sodium to rise because seizure resolution eliminates osmotic demyelination risk is inappropriate because osmotic demyelination is delayed and risk persists despite immediate clinical improvement."
            },
            {
              "id": "C",
              "text": "Option D: Start a vasopressin-receptor antagonist to accelerate free-water excretion is inappropriate because a vaptan increases free-water loss and would accelerate the sodium rise."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give additional hypertonic saline until sodium reaches 140 mEq/L today is inappropriate because further hypertonic saline would magnify an already unsafe correction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start a vasopressin-receptor antagonist to accelerate free-water excretion is inappropriate because a vaptan increases free-water loss and would accelerate the sodium rise."
            },
            {
              "id": "B",
              "text": "Option B: Continue allowing sodium to rise because seizure resolution eliminates osmotic demyelination risk is inappropriate because osmotic demyelination is delayed and risk persists despite immediate clinical improvement."
            },
            {
              "id": "C",
              "text": "Option C: Give additional hypertonic saline until sodium reaches 140 mEq/L today is inappropriate because further hypertonic saline would magnify an already unsafe correction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start a vasopressin-receptor antagonist to accelerate free-water excretion is inappropriate because a vaptan increases free-water loss and would accelerate the sodium rise."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat only the hypokalemia because potassium replacement lowers serum sodium is inappropriate because potassium repletion is necessary but contributes to tonicity correction and cannot replace rescue relowering."
            },
            {
              "id": "B",
              "text": "Option B: Continue allowing sodium to rise because seizure resolution eliminates osmotic demyelination risk is inappropriate because osmotic demyelination is delayed and risk persists despite immediate clinical improvement."
            },
            {
              "id": "C",
              "text": "Option C: Give additional hypertonic saline until sodium reaches 140 mEq/L today is inappropriate because further hypertonic saline would magnify an already unsafe correction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat only the hypokalemia because potassium replacement lowers serum sodium is inappropriate because potassium repletion is necessary but contributes to tonicity correction and cannot replace rescue relowering."
        }
      }
    },
    {
      "externalId": "d5-renal-transplant-artery-thrombosis-emergent-exploration-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "7d0bde5d9aff1f3fdcbcd55bc4e3e3ad042aee88e9a8c3cddc28a1c2c2857454",
        "ranaze_step3_prd": "7d0bde5d9aff1f3fdcbcd55bc4e3e3ad042aee88e9a8c3cddc28a1c2c2857454"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give high-dose methylprednisolone for presumed acute cellular rejection is inappropriate because steroids treat cellular rejection but would delay revascularization of a pulseless graft."
            },
            {
              "id": "B",
              "text": "Option C: Observe for 48 hours because delayed graft function commonly causes absent Doppler flow is inappropriate because delayed graft function preserves Doppler perfusion and cannot safely explain complete absence of flow."
            },
            {
              "id": "C",
              "text": "Option D: Begin oral warfarin and wait for a therapeutic INR is inappropriate because warfarin acts too slowly and does not correct a technical vascular occlusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give high-dose methylprednisolone for presumed acute cellular rejection is inappropriate because steroids treat cellular rejection but would delay revascularization of a pulseless graft."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe for 48 hours because delayed graft function commonly causes absent Doppler flow is inappropriate because delayed graft function preserves Doppler perfusion and cannot safely explain complete absence of flow."
            },
            {
              "id": "B",
              "text": "Option B: Give high-dose methylprednisolone for presumed acute cellular rejection is inappropriate because steroids treat cellular rejection but would delay revascularization of a pulseless graft."
            },
            {
              "id": "C",
              "text": "Option D: Begin oral warfarin and wait for a therapeutic INR is inappropriate because warfarin acts too slowly and does not correct a technical vascular occlusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe for 48 hours because delayed graft function commonly causes absent Doppler flow is inappropriate because delayed graft function preserves Doppler perfusion and cannot safely explain complete absence of flow."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin oral warfarin and wait for a therapeutic INR is inappropriate because warfarin acts too slowly and does not correct a technical vascular occlusion."
            },
            {
              "id": "B",
              "text": "Option B: Give high-dose methylprednisolone for presumed acute cellular rejection is inappropriate because steroids treat cellular rejection but would delay revascularization of a pulseless graft."
            },
            {
              "id": "C",
              "text": "Option C: Observe for 48 hours because delayed graft function commonly causes absent Doppler flow is inappropriate because delayed graft function preserves Doppler perfusion and cannot safely explain complete absence of flow."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin oral warfarin and wait for a therapeutic INR is inappropriate because warfarin acts too slowly and does not correct a technical vascular occlusion."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform percutaneous nephrostomy for occult ureteral obstruction is inappropriate because the lack of hydronephrosis and total absence of vascular perfusion rule against ureteral obstruction as the primary event."
            },
            {
              "id": "B",
              "text": "Option B: Give high-dose methylprednisolone for presumed acute cellular rejection is inappropriate because steroids treat cellular rejection but would delay revascularization of a pulseless graft."
            },
            {
              "id": "C",
              "text": "Option C: Observe for 48 hours because delayed graft function commonly causes absent Doppler flow is inappropriate because delayed graft function preserves Doppler perfusion and cannot safely explain complete absence of flow."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform percutaneous nephrostomy for occult ureteral obstruction is inappropriate because the lack of hydronephrosis and total absence of vascular perfusion rule against ureteral obstruction as the primary event."
        }
      }
    },
    {
      "externalId": "d5-renal-transplant-bk-polyomavirus-nephropathy-reduce-immunosuppression-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "be346e2e389a7f0619ac14738c537f27e30b1e5d6167e6ba5605a479fb8040a6",
        "ranaze_step3_prd": "be346e2e389a7f0619ac14738c537f27e30b1e5d6167e6ba5605a479fb8040a6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulse methylprednisolone followed by antithymocyte globulin is inappropriate because rejection therapy can markedly worsen BK replication when rejection is not demonstrated."
            },
            {
              "id": "B",
              "text": "Option C: Increase tacrolimus exposure to suppress viral replication is inappropriate because higher calcineurin-inhibitor exposure increases the immunosuppressive pressure enabling BK disease."
            },
            {
              "id": "C",
              "text": "Option D: Give routine cidofovir as proven curative monotherapy while leaving immunosuppression unchanged is inappropriate because cidofovir lacks evidence as routine curative therapy and is nephrotoxic."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulse methylprednisolone followed by antithymocyte globulin is inappropriate because rejection therapy can markedly worsen BK replication when rejection is not demonstrated."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase tacrolimus exposure to suppress viral replication is inappropriate because higher calcineurin-inhibitor exposure increases the immunosuppressive pressure enabling BK disease."
            },
            {
              "id": "B",
              "text": "Option B: Pulse methylprednisolone followed by antithymocyte globulin is inappropriate because rejection therapy can markedly worsen BK replication when rejection is not demonstrated."
            },
            {
              "id": "C",
              "text": "Option D: Give routine cidofovir as proven curative monotherapy while leaving immunosuppression unchanged is inappropriate because cidofovir lacks evidence as routine curative therapy and is nephrotoxic."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase tacrolimus exposure to suppress viral replication is inappropriate because higher calcineurin-inhibitor exposure increases the immunosuppressive pressure enabling BK disease."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give routine cidofovir as proven curative monotherapy while leaving immunosuppression unchanged is inappropriate because cidofovir lacks evidence as routine curative therapy and is nephrotoxic."
            },
            {
              "id": "B",
              "text": "Option B: Pulse methylprednisolone followed by antithymocyte globulin is inappropriate because rejection therapy can markedly worsen BK replication when rejection is not demonstrated."
            },
            {
              "id": "C",
              "text": "Option C: Increase tacrolimus exposure to suppress viral replication is inappropriate because higher calcineurin-inhibitor exposure increases the immunosuppressive pressure enabling BK disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give routine cidofovir as proven curative monotherapy while leaving immunosuppression unchanged is inappropriate because cidofovir lacks evidence as routine curative therapy and is nephrotoxic."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform transplant nephrectomy immediately is inappropriate because a potentially salvageable graft should not be removed before evidence-based immunosuppression reduction."
            },
            {
              "id": "B",
              "text": "Option B: Pulse methylprednisolone followed by antithymocyte globulin is inappropriate because rejection therapy can markedly worsen BK replication when rejection is not demonstrated."
            },
            {
              "id": "C",
              "text": "Option C: Increase tacrolimus exposure to suppress viral replication is inappropriate because higher calcineurin-inhibitor exposure increases the immunosuppressive pressure enabling BK disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform transplant nephrectomy immediately is inappropriate because a potentially salvageable graft should not be removed before evidence-based immunosuppression reduction."
        }
      }
    },
    {
      "externalId": "d5-rheumatology-anca-alveolar-hemorrhage-induction-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "a6c85fb2b7b74ca13ec03abc4ad104a51e982bd32da74cbf9c7619ab65ef93ac",
        "ranaze_step3_prd": "a6c85fb2b7b74ca13ec03abc4ad104a51e982bd32da74cbf9c7619ab65ef93ac"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Glucocorticoids alone until pulmonary bleeding resolves is inappropriate because glucocorticoid monotherapy is inadequate for organ-threatening disease."
            },
            {
              "id": "B",
              "text": "Option C: Plasma exchange alone without immunosuppression is inappropriate because exchange does not suppress ongoing autoantibody production by itself."
            },
            {
              "id": "C",
              "text": "Option D: Methotrexate monotherapy is inappropriate because methotrexate is inappropriate with organ-threatening lung and kidney disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Glucocorticoids alone until pulmonary bleeding resolves is inappropriate because glucocorticoid monotherapy is inadequate for organ-threatening disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plasma exchange alone without immunosuppression is inappropriate because exchange does not suppress ongoing autoantibody production by itself."
            },
            {
              "id": "B",
              "text": "Option A: Glucocorticoids alone until pulmonary bleeding resolves is inappropriate because glucocorticoid monotherapy is inadequate for organ-threatening disease."
            },
            {
              "id": "C",
              "text": "Option D: Methotrexate monotherapy is inappropriate because methotrexate is inappropriate with organ-threatening lung and kidney disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plasma exchange alone without immunosuppression is inappropriate because exchange does not suppress ongoing autoantibody production by itself."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Methotrexate monotherapy is inappropriate because methotrexate is inappropriate with organ-threatening lung and kidney disease."
            },
            {
              "id": "B",
              "text": "Option A: Glucocorticoids alone until pulmonary bleeding resolves is inappropriate because glucocorticoid monotherapy is inadequate for organ-threatening disease."
            },
            {
              "id": "C",
              "text": "Option C: Plasma exchange alone without immunosuppression is inappropriate because exchange does not suppress ongoing autoantibody production by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Methotrexate monotherapy is inappropriate because methotrexate is inappropriate with organ-threatening lung and kidney disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mepolizumab plus an inhaled glucocorticoid is inappropriate because mepolizumab targets eosinophilic disease, not PR3-positive GPA."
            },
            {
              "id": "B",
              "text": "Option A: Glucocorticoids alone until pulmonary bleeding resolves is inappropriate because glucocorticoid monotherapy is inadequate for organ-threatening disease."
            },
            {
              "id": "C",
              "text": "Option C: Plasma exchange alone without immunosuppression is inappropriate because exchange does not suppress ongoing autoantibody production by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mepolizumab plus an inhaled glucocorticoid is inappropriate because mepolizumab targets eosinophilic disease, not PR3-positive GPA."
        }
      }
    },
    {
      "externalId": "d5-rheumatology-egpa-cardiac-severe-cyclophosphamide-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "d774c7b3777904acb142bbee40a3bf1a397dd7a8bd8185ab043daa2aa7debc07",
        "ranaze_step3_prd": "d774c7b3777904acb142bbee40a3bf1a397dd7a8bd8185ab043daa2aa7debc07"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mepolizumab alone is inappropriate because iL-5 blockade alone is not established for severe cardiac EGPA."
            },
            {
              "id": "B",
              "text": "Option C: Inhaled glucocorticoid plus montelukast is inappropriate because airway-controller therapy cannot treat systemic necrotizing vasculitis."
            },
            {
              "id": "C",
              "text": "Option D: Methotrexate alone is inappropriate because methotrexate monotherapy is insufficient for severe organ disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mepolizumab alone is inappropriate because iL-5 blockade alone is not established for severe cardiac EGPA."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inhaled glucocorticoid plus montelukast is inappropriate because airway-controller therapy cannot treat systemic necrotizing vasculitis."
            },
            {
              "id": "B",
              "text": "Option A: Mepolizumab alone is inappropriate because iL-5 blockade alone is not established for severe cardiac EGPA."
            },
            {
              "id": "C",
              "text": "Option D: Methotrexate alone is inappropriate because methotrexate monotherapy is insufficient for severe organ disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inhaled glucocorticoid plus montelukast is inappropriate because airway-controller therapy cannot treat systemic necrotizing vasculitis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Methotrexate alone is inappropriate because methotrexate monotherapy is insufficient for severe organ disease."
            },
            {
              "id": "B",
              "text": "Option A: Mepolizumab alone is inappropriate because iL-5 blockade alone is not established for severe cardiac EGPA."
            },
            {
              "id": "C",
              "text": "Option C: Inhaled glucocorticoid plus montelukast is inappropriate because airway-controller therapy cannot treat systemic necrotizing vasculitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Methotrexate alone is inappropriate because methotrexate monotherapy is insufficient for severe organ disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Omalizumab alone is inappropriate because igE blockade does not induce remission of severe EGPA vasculitis."
            },
            {
              "id": "B",
              "text": "Option A: Mepolizumab alone is inappropriate because iL-5 blockade alone is not established for severe cardiac EGPA."
            },
            {
              "id": "C",
              "text": "Option C: Inhaled glucocorticoid plus montelukast is inappropriate because airway-controller therapy cannot treat systemic necrotizing vasculitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Omalizumab alone is inappropriate because igE blockade does not induce remission of severe EGPA vasculitis."
        }
      }
    },
    {
      "externalId": "d5-rheumatology-proliferative-lupus-nephritis-triple-therapy-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "5b4da9860a025c7a3bc26474f39c07456da914fc766c5d7b36cd6d5d00eaec1b",
        "ranaze_step3_prd": "5b4da9860a025c7a3bc26474f39c07456da914fc766c5d7b36cd6d5d00eaec1b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hydroxychloroquine alone is inappropriate because hydroxychloroquine is foundational SLE therapy but inadequate alone for proliferative nephritis."
            },
            {
              "id": "B",
              "text": "Option B: High-dose glucocorticoids alone is inappropriate because steroids alone produce excess toxicity and insufficient durable control."
            },
            {
              "id": "C",
              "text": "Option D: A nonsteroidal anti-inflammatory drug plus an ACE inhibitor only is inappropriate because supportive antiproteinuric therapy does not control immune-mediated glomerular injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hydroxychloroquine alone is inappropriate because hydroxychloroquine is foundational SLE therapy but inadequate alone for proliferative nephritis."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose glucocorticoids alone is inappropriate because steroids alone produce excess toxicity and insufficient durable control."
            },
            {
              "id": "B",
              "text": "Option A: Hydroxychloroquine alone is inappropriate because hydroxychloroquine is foundational SLE therapy but inadequate alone for proliferative nephritis."
            },
            {
              "id": "C",
              "text": "Option D: A nonsteroidal anti-inflammatory drug plus an ACE inhibitor only is inappropriate because supportive antiproteinuric therapy does not control immune-mediated glomerular injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose glucocorticoids alone is inappropriate because steroids alone produce excess toxicity and insufficient durable control."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A nonsteroidal anti-inflammatory drug plus an ACE inhibitor only is inappropriate because supportive antiproteinuric therapy does not control immune-mediated glomerular injury."
            },
            {
              "id": "B",
              "text": "Option A: Hydroxychloroquine alone is inappropriate because hydroxychloroquine is foundational SLE therapy but inadequate alone for proliferative nephritis."
            },
            {
              "id": "C",
              "text": "Option B: High-dose glucocorticoids alone is inappropriate because steroids alone produce excess toxicity and insufficient durable control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A nonsteroidal anti-inflammatory drug plus an ACE inhibitor only is inappropriate because supportive antiproteinuric therapy does not control immune-mediated glomerular injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Methotrexate plus low-dose prednisone is inappropriate because methotrexate is not an induction agent for proliferative lupus nephritis."
            },
            {
              "id": "B",
              "text": "Option A: Hydroxychloroquine alone is inappropriate because hydroxychloroquine is foundational SLE therapy but inadequate alone for proliferative nephritis."
            },
            {
              "id": "C",
              "text": "Option B: High-dose glucocorticoids alone is inappropriate because steroids alone produce excess toxicity and insufficient durable control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Methotrexate plus low-dose prednisone is inappropriate because methotrexate is not an induction agent for proliferative lupus nephritis."
        }
      }
    },
    {
      "externalId": "d5-surgical-critical-care-abdominal-compartment-decompression-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "1329c6de1b689df4c0390c234ab317e0e379ba9f34ea701508d8dabd7cb0ecdd",
        "ranaze_step3_prd": "1329c6de1b689df4c0390c234ab317e0e379ba9f34ea701508d8dabd7cb0ecdd"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue observation because intra-abdominal pressure alone does not require treatment is inappropriate because the combination of pressure above 20 mm Hg and new pulmonary, renal, and perfusion failure defines overt abdominal compartment syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Give additional crystalloid to increase abdominal perfusion pressure is inappropriate because more crystalloid increases edema and intra-abdominal pressure and can further impair organ perfusion."
            },
            {
              "id": "C",
              "text": "Option D: Start high-dose loop diuretics and reassess the bladder pressure tomorrow is inappropriate because diuresis may help selected patients with intra-abdominal hypertension after stabilization, but it is inadequate for rapidly progressive multiorgan dysfunction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue observation because intra-abdominal pressure alone does not require treatment is inappropriate because the combination of pressure above 20 mm Hg and new pulmonary, renal, and perfusion failure defines overt abdominal compartment syndrome."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give additional crystalloid to increase abdominal perfusion pressure is inappropriate because more crystalloid increases edema and intra-abdominal pressure and can further impair organ perfusion."
            },
            {
              "id": "B",
              "text": "Option A: Continue observation because intra-abdominal pressure alone does not require treatment is inappropriate because the combination of pressure above 20 mm Hg and new pulmonary, renal, and perfusion failure defines overt abdominal compartment syndrome."
            },
            {
              "id": "C",
              "text": "Option D: Start high-dose loop diuretics and reassess the bladder pressure tomorrow is inappropriate because diuresis may help selected patients with intra-abdominal hypertension after stabilization, but it is inadequate for rapidly progressive multiorgan dysfunction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give additional crystalloid to increase abdominal perfusion pressure is inappropriate because more crystalloid increases edema and intra-abdominal pressure and can further impair organ perfusion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start high-dose loop diuretics and reassess the bladder pressure tomorrow is inappropriate because diuresis may help selected patients with intra-abdominal hypertension after stabilization, but it is inadequate for rapidly progressive multiorgan dysfunction."
            },
            {
              "id": "B",
              "text": "Option A: Continue observation because intra-abdominal pressure alone does not require treatment is inappropriate because the combination of pressure above 20 mm Hg and new pulmonary, renal, and perfusion failure defines overt abdominal compartment syndrome."
            },
            {
              "id": "C",
              "text": "Option B: Give additional crystalloid to increase abdominal perfusion pressure is inappropriate because more crystalloid increases edema and intra-abdominal pressure and can further impair organ perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start high-dose loop diuretics and reassess the bladder pressure tomorrow is inappropriate because diuresis may help selected patients with intra-abdominal hypertension after stabilization, but it is inadequate for rapidly progressive multiorgan dysfunction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase positive end-expiratory pressure to match the bladder pressure is inappropriate because higher PEEP may further impair venous return and does not relieve the intra-abdominal pressure."
            },
            {
              "id": "B",
              "text": "Option A: Continue observation because intra-abdominal pressure alone does not require treatment is inappropriate because the combination of pressure above 20 mm Hg and new pulmonary, renal, and perfusion failure defines overt abdominal compartment syndrome."
            },
            {
              "id": "C",
              "text": "Option B: Give additional crystalloid to increase abdominal perfusion pressure is inappropriate because more crystalloid increases edema and intra-abdominal pressure and can further impair organ perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase positive end-expiratory pressure to match the bladder pressure is inappropriate because higher PEEP may further impair venous return and does not relieve the intra-abdominal pressure."
        }
      }
    },
    {
      "externalId": "d5-surgical-critical-care-nonocclusive-mesenteric-ischemia-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "2daa94ee1acb038903e517fc50eb6bd8d8aafeb8cf2e3e4938037095ab2fcc47",
        "ranaze_step3_prd": "2daa94ee1acb038903e517fc50eb6bd8d8aafeb8cf2e3e4938037095ab2fcc47"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform embolectomy of the superior mesenteric artery is inappropriate because there is no embolus to remove; the diffuse branch narrowing and low-flow context indicate nonocclusive ischemia."
            },
            {
              "id": "B",
              "text": "Option C: Administer an oral osmotic laxative and continue enteral feeding is inappropriate because enteral loading can increase oxygen demand in ischemic bowel, and laxatives do not correct hypoperfusion."
            },
            {
              "id": "C",
              "text": "Option D: Begin high-dose corticosteroids for presumed mesenteric vasculitis is inappropriate because the postoperative low-output and vasopressor context is characteristic of NOMI rather than primary vasculitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform embolectomy of the superior mesenteric artery is inappropriate because there is no embolus to remove; the diffuse branch narrowing and low-flow context indicate nonocclusive ischemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer an oral osmotic laxative and continue enteral feeding is inappropriate because enteral loading can increase oxygen demand in ischemic bowel, and laxatives do not correct hypoperfusion."
            },
            {
              "id": "B",
              "text": "Option A: Perform embolectomy of the superior mesenteric artery is inappropriate because there is no embolus to remove; the diffuse branch narrowing and low-flow context indicate nonocclusive ischemia."
            },
            {
              "id": "C",
              "text": "Option D: Begin high-dose corticosteroids for presumed mesenteric vasculitis is inappropriate because the postoperative low-output and vasopressor context is characteristic of NOMI rather than primary vasculitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer an oral osmotic laxative and continue enteral feeding is inappropriate because enteral loading can increase oxygen demand in ischemic bowel, and laxatives do not correct hypoperfusion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin high-dose corticosteroids for presumed mesenteric vasculitis is inappropriate because the postoperative low-output and vasopressor context is characteristic of NOMI rather than primary vasculitis."
            },
            {
              "id": "B",
              "text": "Option A: Perform embolectomy of the superior mesenteric artery is inappropriate because there is no embolus to remove; the diffuse branch narrowing and low-flow context indicate nonocclusive ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Administer an oral osmotic laxative and continue enteral feeding is inappropriate because enteral loading can increase oxygen demand in ischemic bowel, and laxatives do not correct hypoperfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin high-dose corticosteroids for presumed mesenteric vasculitis is inappropriate because the postoperative low-output and vasopressor context is characteristic of NOMI rather than primary vasculitis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe until peritoneal signs develop because the major vessels are patent is inappropriate because nOMI progresses rapidly; treatment should begin before transmural necrosis produces peritoneal signs."
            },
            {
              "id": "B",
              "text": "Option A: Perform embolectomy of the superior mesenteric artery is inappropriate because there is no embolus to remove; the diffuse branch narrowing and low-flow context indicate nonocclusive ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Administer an oral osmotic laxative and continue enteral feeding is inappropriate because enteral loading can increase oxygen demand in ischemic bowel, and laxatives do not correct hypoperfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe until peritoneal signs develop because the major vessels are patent is inappropriate because nOMI progresses rapidly; treatment should begin before transmural necrosis produces peritoneal signs."
        }
      }
    },
    {
      "externalId": "d5-surgical-postoperative-colorectal-anastomotic-leak-sepsis-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "37db6dc776312ec72627e034a5d8057ef78d824b23858671f14e553e1c54b1dc",
        "ranaze_step3_prd": "37db6dc776312ec72627e034a5d8057ef78d824b23858671f14e553e1c54b1dc"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain CT of the abdomen and pelvis with rectal contrast before consulting surgery is inappropriate because imaging delays life-saving source control in an unstable patient with direct evidence of free leak and generalized peritonitis."
            },
            {
              "id": "B",
              "text": "Option C: Remove the pelvic drain and perform colonoscopy after bowel preparation is inappropriate because bowel preparation and colonoscopy risk further contamination and cannot control diffuse intra-abdominal sepsis."
            },
            {
              "id": "C",
              "text": "Option D: Treat with antibiotics alone because a drain is already present is inappropriate because a preexisting drain does not control free fecal contamination with peritonitis and shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain CT of the abdomen and pelvis with rectal contrast before consulting surgery is inappropriate because imaging delays life-saving source control in an unstable patient with direct evidence of free leak and generalized peritonitis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remove the pelvic drain and perform colonoscopy after bowel preparation is inappropriate because bowel preparation and colonoscopy risk further contamination and cannot control diffuse intra-abdominal sepsis."
            },
            {
              "id": "B",
              "text": "Option A: Obtain CT of the abdomen and pelvis with rectal contrast before consulting surgery is inappropriate because imaging delays life-saving source control in an unstable patient with direct evidence of free leak and generalized peritonitis."
            },
            {
              "id": "C",
              "text": "Option D: Treat with antibiotics alone because a drain is already present is inappropriate because a preexisting drain does not control free fecal contamination with peritonitis and shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remove the pelvic drain and perform colonoscopy after bowel preparation is inappropriate because bowel preparation and colonoscopy risk further contamination and cannot control diffuse intra-abdominal sepsis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with antibiotics alone because a drain is already present is inappropriate because a preexisting drain does not control free fecal contamination with peritonitis and shock."
            },
            {
              "id": "B",
              "text": "Option A: Obtain CT of the abdomen and pelvis with rectal contrast before consulting surgery is inappropriate because imaging delays life-saving source control in an unstable patient with direct evidence of free leak and generalized peritonitis."
            },
            {
              "id": "C",
              "text": "Option C: Remove the pelvic drain and perform colonoscopy after bowel preparation is inappropriate because bowel preparation and colonoscopy risk further contamination and cannot control diffuse intra-abdominal sepsis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with antibiotics alone because a drain is already present is inappropriate because a preexisting drain does not control free fecal contamination with peritonitis and shock."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule percutaneous drainage after hemodynamic stability returns spontaneously is inappropriate because percutaneous drainage is for selected stable, contained abscesses, not diffuse peritonitis with refractory hypotension."
            },
            {
              "id": "B",
              "text": "Option A: Obtain CT of the abdomen and pelvis with rectal contrast before consulting surgery is inappropriate because imaging delays life-saving source control in an unstable patient with direct evidence of free leak and generalized peritonitis."
            },
            {
              "id": "C",
              "text": "Option C: Remove the pelvic drain and perform colonoscopy after bowel preparation is inappropriate because bowel preparation and colonoscopy risk further contamination and cannot control diffuse intra-abdominal sepsis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule percutaneous drainage after hemodynamic stability returns spontaneously is inappropriate because percutaneous drainage is for selected stable, contained abscesses, not diffuse peritonitis with refractory hypotension."
        }
      }
    },
    {
      "externalId": "d5-toxicology-digoxin-hyperkalemia-immune-fab-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "337c7faac7596553a1245628281b705acac35a41cffbbc3418402ba50fd63ea5",
        "ranaze_step3_prd": "337c7faac7596553a1245628281b705acac35a41cffbbc3418402ba50fd63ea5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hemodialysis alone is inappropriate because digoxin is poorly dialyzable due to extensive tissue distribution."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous calcium channel blocker is inappropriate because calcium-channel blockade worsens bradycardia and hypotension."
            },
            {
              "id": "C",
              "text": "Option D: Electrical cardioversion as the only treatment is inappropriate because cardioversion alone does not neutralize digoxin and may provoke arrhythmia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hemodialysis alone is inappropriate because digoxin is poorly dialyzable due to extensive tissue distribution."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous calcium channel blocker is inappropriate because calcium-channel blockade worsens bradycardia and hypotension."
            },
            {
              "id": "B",
              "text": "Option B: Hemodialysis alone is inappropriate because digoxin is poorly dialyzable due to extensive tissue distribution."
            },
            {
              "id": "C",
              "text": "Option D: Electrical cardioversion as the only treatment is inappropriate because cardioversion alone does not neutralize digoxin and may provoke arrhythmia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous calcium channel blocker is inappropriate because calcium-channel blockade worsens bradycardia and hypotension."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electrical cardioversion as the only treatment is inappropriate because cardioversion alone does not neutralize digoxin and may provoke arrhythmia."
            },
            {
              "id": "B",
              "text": "Option B: Hemodialysis alone is inappropriate because digoxin is poorly dialyzable due to extensive tissue distribution."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous calcium channel blocker is inappropriate because calcium-channel blockade worsens bradycardia and hypotension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electrical cardioversion as the only treatment is inappropriate because cardioversion alone does not neutralize digoxin and may provoke arrhythmia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sodium polystyrene sulfonate alone is inappropriate because a slow potassium binder cannot treat immediate unstable poisoning."
            },
            {
              "id": "B",
              "text": "Option B: Hemodialysis alone is inappropriate because digoxin is poorly dialyzable due to extensive tissue distribution."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous calcium channel blocker is inappropriate because calcium-channel blockade worsens bradycardia and hypotension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sodium polystyrene sulfonate alone is inappropriate because a slow potassium binder cannot treat immediate unstable poisoning."
        }
      }
    },
    {
      "externalId": "d5-toxicology-methanol-vision-fomepizole-dialysis-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "ab04ac4fb0b766d611a8f0ab7b0f1e695b46900ca8e4a3099f9b2957496f3144",
        "ranaze_step3_prd": "ab04ac4fb0b766d611a8f0ab7b0f1e695b46900ca8e4a3099f9b2957496f3144"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for the methanol level before administering an antidote is inappropriate because delay permits additional toxic metabolite formation."
            },
            {
              "id": "B",
              "text": "Option C: Administer activated charcoal alone is inappropriate because charcoal poorly adsorbs alcohols and cannot treat established toxicity."
            },
            {
              "id": "C",
              "text": "Option D: Give naloxone and observe is inappropriate because naloxone treats opioid toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for the methanol level before administering an antidote is inappropriate because delay permits additional toxic metabolite formation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer activated charcoal alone is inappropriate because charcoal poorly adsorbs alcohols and cannot treat established toxicity."
            },
            {
              "id": "B",
              "text": "Option A: Wait for the methanol level before administering an antidote is inappropriate because delay permits additional toxic metabolite formation."
            },
            {
              "id": "C",
              "text": "Option D: Give naloxone and observe is inappropriate because naloxone treats opioid toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer activated charcoal alone is inappropriate because charcoal poorly adsorbs alcohols and cannot treat established toxicity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give naloxone and observe is inappropriate because naloxone treats opioid toxicity."
            },
            {
              "id": "B",
              "text": "Option A: Wait for the methanol level before administering an antidote is inappropriate because delay permits additional toxic metabolite formation."
            },
            {
              "id": "C",
              "text": "Option C: Administer activated charcoal alone is inappropriate because charcoal poorly adsorbs alcohols and cannot treat established toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give naloxone and observe is inappropriate because naloxone treats opioid toxicity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with intravenous ethanol only after vision loss becomes permanent is inappropriate because ethanol is an alternative ADH blocker, but therapy must begin now and dialysis is still indicated."
            },
            {
              "id": "B",
              "text": "Option A: Wait for the methanol level before administering an antidote is inappropriate because delay permits additional toxic metabolite formation."
            },
            {
              "id": "C",
              "text": "Option C: Administer activated charcoal alone is inappropriate because charcoal poorly adsorbs alcohols and cannot treat established toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with intravenous ethanol only after vision loss becomes permanent is inappropriate because ethanol is an alternative ADH blocker, but therapy must begin now and dialysis is still indicated."
        }
      }
    },
    {
      "externalId": "d5-toxicology-tca-wide-qrs-bicarbonate-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "66d616096fd8f68b279b5d00e01cf42478620b41cc0f03d8696f7575864ec60f",
        "ranaze_step3_prd": "66d616096fd8f68b279b5d00e01cf42478620b41cc0f03d8696f7575864ec60f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous procainamide is inappropriate because procainamide adds sodium-channel blockade and can worsen instability."
            },
            {
              "id": "B",
              "text": "Option C: Physostigmine is dangerous with TCA conduction toxicity."
            },
            {
              "id": "C",
              "text": "Option D: Flumazenil is unrelated and increases seizure risk in mixed overdose."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous procainamide is inappropriate because procainamide adds sodium-channel blockade and can worsen instability."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Physostigmine is dangerous with TCA conduction toxicity."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous procainamide is inappropriate because procainamide adds sodium-channel blockade and can worsen instability."
            },
            {
              "id": "C",
              "text": "Option D: Flumazenil is unrelated and increases seizure risk in mixed overdose."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Physostigmine is dangerous with TCA conduction toxicity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Flumazenil is unrelated and increases seizure risk in mixed overdose."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous procainamide is inappropriate because procainamide adds sodium-channel blockade and can worsen instability."
            },
            {
              "id": "C",
              "text": "Option C: Physostigmine is dangerous with TCA conduction toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Flumazenil is unrelated and increases seizure risk in mixed overdose."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral activated charcoal without securing the airway is inappropriate because charcoal may be considered only after airway protection and does not replace resuscitation."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous procainamide is inappropriate because procainamide adds sodium-channel blockade and can worsen instability."
            },
            {
              "id": "C",
              "text": "Option C: Physostigmine is dangerous with TCA conduction toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral activated charcoal without securing the airway is inappropriate because charcoal may be considered only after airway protection and does not replace resuscitation."
        }
      }
    },
    {
      "externalId": "d5-transfusion-alloimmune-platelet-refractoriness-hla-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "3edafc5df365205e03d7e282c532462b8a156c020092306b5f83cf953f5b36e3",
        "ranaze_step3_prd": "3edafc5df365205e03d7e282c532462b8a156c020092306b5f83cf953f5b36e3"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue empiric random-donor platelet transfusions at progressively shorter intervals is inappropriate because more incompatible exposure is ineffective and may intensify alloimmunization."
            },
            {
              "id": "B",
              "text": "Option C: Give red blood cells instead because they contain sufficient platelets is inappropriate because red-cell products do not provide a therapeutic platelet dose."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous vitamin K before each random platelet unit is inappropriate because vitamin K corrects vitamin K-dependent factor deficiency, not HLA alloimmunization."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue empiric random-donor platelet transfusions at progressively shorter intervals is inappropriate because more incompatible exposure is ineffective and may intensify alloimmunization."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give red blood cells instead because they contain sufficient platelets is inappropriate because red-cell products do not provide a therapeutic platelet dose."
            },
            {
              "id": "B",
              "text": "Option A: Continue empiric random-donor platelet transfusions at progressively shorter intervals is inappropriate because more incompatible exposure is ineffective and may intensify alloimmunization."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous vitamin K before each random platelet unit is inappropriate because vitamin K corrects vitamin K-dependent factor deficiency, not HLA alloimmunization."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give red blood cells instead because they contain sufficient platelets is inappropriate because red-cell products do not provide a therapeutic platelet dose."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous vitamin K before each random platelet unit is inappropriate because vitamin K corrects vitamin K-dependent factor deficiency, not HLA alloimmunization."
            },
            {
              "id": "B",
              "text": "Option A: Continue empiric random-donor platelet transfusions at progressively shorter intervals is inappropriate because more incompatible exposure is ineffective and may intensify alloimmunization."
            },
            {
              "id": "C",
              "text": "Option C: Give red blood cells instead because they contain sufficient platelets is inappropriate because red-cell products do not provide a therapeutic platelet dose."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous vitamin K before each random platelet unit is inappropriate because vitamin K corrects vitamin K-dependent factor deficiency, not HLA alloimmunization."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold all future platelet support regardless of bleeding risk is inappropriate because compatible support remains necessary when clinically indicated."
            },
            {
              "id": "B",
              "text": "Option A: Continue empiric random-donor platelet transfusions at progressively shorter intervals is inappropriate because more incompatible exposure is ineffective and may intensify alloimmunization."
            },
            {
              "id": "C",
              "text": "Option C: Give red blood cells instead because they contain sufficient platelets is inappropriate because red-cell products do not provide a therapeutic platelet dose."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold all future platelet support regardless of bleeding risk is inappropriate because compatible support remains necessary when clinically indicated."
        }
      }
    },
    {
      "externalId": "d5-transfusion-sickle-hyperhemolysis-immunosuppression-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "a345926fd6d682cf243e7f6fb44e4dd39bbfaa6f3303d5223ecc27cc21276248",
        "ranaze_step3_prd": "a345926fd6d682cf243e7f6fb44e4dd39bbfaa6f3303d5223ecc27cc21276248"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give additional unmatched red cells immediately until hemoglobin exceeds 10 g/dL is inappropriate because more transfusion can amplify hyperhemolysis and is reserved for life-threatening anemia."
            },
            {
              "id": "B",
              "text": "Option C: Treat as an uncomplicated vaso-occlusive crisis with analgesia alone is inappropriate because analgesia alone misses a potentially fatal transfusion complication."
            },
            {
              "id": "C",
              "text": "Option D: Perform splenectomy for presumed sequestration is inappropriate because the laboratory pattern is hemolysis, not acute splenic pooling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give additional unmatched red cells immediately until hemoglobin exceeds 10 g/dL is inappropriate because more transfusion can amplify hyperhemolysis and is reserved for life-threatening anemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat as an uncomplicated vaso-occlusive crisis with analgesia alone is inappropriate because analgesia alone misses a potentially fatal transfusion complication."
            },
            {
              "id": "B",
              "text": "Option A: Give additional unmatched red cells immediately until hemoglobin exceeds 10 g/dL is inappropriate because more transfusion can amplify hyperhemolysis and is reserved for life-threatening anemia."
            },
            {
              "id": "C",
              "text": "Option D: Perform splenectomy for presumed sequestration is inappropriate because the laboratory pattern is hemolysis, not acute splenic pooling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat as an uncomplicated vaso-occlusive crisis with analgesia alone is inappropriate because analgesia alone misses a potentially fatal transfusion complication."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform splenectomy for presumed sequestration is inappropriate because the laboratory pattern is hemolysis, not acute splenic pooling."
            },
            {
              "id": "B",
              "text": "Option A: Give additional unmatched red cells immediately until hemoglobin exceeds 10 g/dL is inappropriate because more transfusion can amplify hyperhemolysis and is reserved for life-threatening anemia."
            },
            {
              "id": "C",
              "text": "Option C: Treat as an uncomplicated vaso-occlusive crisis with analgesia alone is inappropriate because analgesia alone misses a potentially fatal transfusion complication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform splenectomy for presumed sequestration is inappropriate because the laboratory pattern is hemolysis, not acute splenic pooling."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer iron chelation as the immediate treatment is inappropriate because chelation addresses chronic iron burden, not acute immune hemolysis."
            },
            {
              "id": "B",
              "text": "Option A: Give additional unmatched red cells immediately until hemoglobin exceeds 10 g/dL is inappropriate because more transfusion can amplify hyperhemolysis and is reserved for life-threatening anemia."
            },
            {
              "id": "C",
              "text": "Option C: Treat as an uncomplicated vaso-occlusive crisis with analgesia alone is inappropriate because analgesia alone misses a potentially fatal transfusion complication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer iron chelation as the immediate treatment is inappropriate because chelation addresses chronic iron burden, not acute immune hemolysis."
        }
      }
    },
    {
      "externalId": "d5-transfusion-taco-stop-diurese-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "f0c01b02c8ee4c7313f58c643b3d1af3a6373f298565a97a40e2b10ce5c23857",
        "ranaze_step3_prd": "f0c01b02c8ee4c7313f58c643b3d1af3a6373f298565a97a40e2b10ce5c23857"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue the transfusion at a slower rate and give diphenhydramine is inappropriate because continuing the implicated transfusion is unsafe."
            },
            {
              "id": "B",
              "text": "Option C: Administer additional crystalloid for presumed transfusion-related acute lung injury is inappropriate because additional volume worsens circulatory overload."
            },
            {
              "id": "C",
              "text": "Option D: Begin broad-spectrum antibiotics and wait for blood-culture results is inappropriate because infection does not explain the tight temporal relationship and overload findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue the transfusion at a slower rate and give diphenhydramine is inappropriate because continuing the implicated transfusion is unsafe."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer additional crystalloid for presumed transfusion-related acute lung injury is inappropriate because additional volume worsens circulatory overload."
            },
            {
              "id": "B",
              "text": "Option A: Continue the transfusion at a slower rate and give diphenhydramine is inappropriate because continuing the implicated transfusion is unsafe."
            },
            {
              "id": "C",
              "text": "Option D: Begin broad-spectrum antibiotics and wait for blood-culture results is inappropriate because infection does not explain the tight temporal relationship and overload findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer additional crystalloid for presumed transfusion-related acute lung injury is inappropriate because additional volume worsens circulatory overload."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin broad-spectrum antibiotics and wait for blood-culture results is inappropriate because infection does not explain the tight temporal relationship and overload findings."
            },
            {
              "id": "B",
              "text": "Option A: Continue the transfusion at a slower rate and give diphenhydramine is inappropriate because continuing the implicated transfusion is unsafe."
            },
            {
              "id": "C",
              "text": "Option C: Administer additional crystalloid for presumed transfusion-related acute lung injury is inappropriate because additional volume worsens circulatory overload."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin broad-spectrum antibiotics and wait for blood-culture results is inappropriate because infection does not explain the tight temporal relationship and overload findings."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform emergent plasma exchange is inappropriate because plasma exchange has no role in hydrostatic overload."
            },
            {
              "id": "B",
              "text": "Option A: Continue the transfusion at a slower rate and give diphenhydramine is inappropriate because continuing the implicated transfusion is unsafe."
            },
            {
              "id": "C",
              "text": "Option C: Administer additional crystalloid for presumed transfusion-related acute lung injury is inappropriate because additional volume worsens circulatory overload."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform emergent plasma exchange is inappropriate because plasma exchange has no role in hydrostatic overload."
        }
      }
    },
    {
      "externalId": "d5-transplant-cmv-colitis-iv-ganciclovir-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "62b6c917168b8d1728354909f95fdc8cec24346052f5b79770757b0eb0688b07",
        "ranaze_step3_prd": "62b6c917168b8d1728354909f95fdc8cec24346052f5b79770757b0eb0688b07"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral acyclovir and no change in transplant medications is inappropriate because acyclovir lacks adequate activity for established CMV disease."
            },
            {
              "id": "B",
              "text": "Option C: Increase mycophenolate to prevent rejection caused by diarrhea is inappropriate because more mycophenolate worsens viral control and marrow suppression."
            },
            {
              "id": "C",
              "text": "Option D: Treat with intravenous immune globulin alone is inappropriate because immune globulin is not adequate monotherapy for CMV colitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral acyclovir and no change in transplant medications is inappropriate because acyclovir lacks adequate activity for established CMV disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase mycophenolate to prevent rejection caused by diarrhea is inappropriate because more mycophenolate worsens viral control and marrow suppression."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir and no change in transplant medications is inappropriate because acyclovir lacks adequate activity for established CMV disease."
            },
            {
              "id": "C",
              "text": "Option D: Treat with intravenous immune globulin alone is inappropriate because immune globulin is not adequate monotherapy for CMV colitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase mycophenolate to prevent rejection caused by diarrhea is inappropriate because more mycophenolate worsens viral control and marrow suppression."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with intravenous immune globulin alone is inappropriate because immune globulin is not adequate monotherapy for CMV colitis."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir and no change in transplant medications is inappropriate because acyclovir lacks adequate activity for established CMV disease."
            },
            {
              "id": "C",
              "text": "Option C: Increase mycophenolate to prevent rejection caused by diarrhea is inappropriate because more mycophenolate worsens viral control and marrow suppression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with intravenous immune globulin alone is inappropriate because immune globulin is not adequate monotherapy for CMV colitis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop all antiviral therapy once the fever resolves is inappropriate because clinical improvement alone is insufficient without an adequate course and virologic response."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir and no change in transplant medications is inappropriate because acyclovir lacks adequate activity for established CMV disease."
            },
            {
              "id": "C",
              "text": "Option C: Increase mycophenolate to prevent rejection caused by diarrhea is inappropriate because more mycophenolate worsens viral control and marrow suppression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop all antiviral therapy once the fever resolves is inappropriate because clinical improvement alone is insufficient without an adequate course and virologic response."
        }
      }
    },
    {
      "externalId": "d5-transplant-ebv-ptld-reduce-immunosuppression-rituximab-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "e4f245608dc091cfd9b7c23d533101333bf33d1677cd8e7d915277b6b48f4384",
        "ranaze_step3_prd": "e4f245608dc091cfd9b7c23d533101333bf33d1677cd8e7d915277b6b48f4384"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase tacrolimus to prevent rejection during lymphoma treatment is inappropriate because greater immunosuppression promotes PTLD progression."
            },
            {
              "id": "B",
              "text": "Option C: Treat with acyclovir alone is inappropriate because acyclovir does not clear latent EBV-driven tumor cells."
            },
            {
              "id": "C",
              "text": "Option D: Observe until the EBV DNA doubles again is inappropriate because biopsy-proven aggressive disease requires prompt treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase tacrolimus to prevent rejection during lymphoma treatment is inappropriate because greater immunosuppression promotes PTLD progression."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with acyclovir alone is inappropriate because acyclovir does not clear latent EBV-driven tumor cells."
            },
            {
              "id": "B",
              "text": "Option A: Increase tacrolimus to prevent rejection during lymphoma treatment is inappropriate because greater immunosuppression promotes PTLD progression."
            },
            {
              "id": "C",
              "text": "Option D: Observe until the EBV DNA doubles again is inappropriate because biopsy-proven aggressive disease requires prompt treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with acyclovir alone is inappropriate because acyclovir does not clear latent EBV-driven tumor cells."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe until the EBV DNA doubles again is inappropriate because biopsy-proven aggressive disease requires prompt treatment."
            },
            {
              "id": "B",
              "text": "Option A: Increase tacrolimus to prevent rejection during lymphoma treatment is inappropriate because greater immunosuppression promotes PTLD progression."
            },
            {
              "id": "C",
              "text": "Option C: Treat with acyclovir alone is inappropriate because acyclovir does not clear latent EBV-driven tumor cells."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe until the EBV DNA doubles again is inappropriate because biopsy-proven aggressive disease requires prompt treatment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform emergent heart retransplantation is inappropriate because retransplantation does not treat systemic lymphoma."
            },
            {
              "id": "B",
              "text": "Option A: Increase tacrolimus to prevent rejection during lymphoma treatment is inappropriate because greater immunosuppression promotes PTLD progression."
            },
            {
              "id": "C",
              "text": "Option C: Treat with acyclovir alone is inappropriate because acyclovir does not clear latent EBV-driven tumor cells."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform emergent heart retransplantation is inappropriate because retransplantation does not treat systemic lymphoma."
        }
      }
    },
    {
      "externalId": "d5-transplant-kidney-active-antibody-rejection-plex-ivig-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "1992dc795a435c231a4f7a1dab783992784baec21fa62bd701482730a04422ee",
        "ranaze_step3_prd": "1992dc795a435c231a4f7a1dab783992784baec21fa62bd701482730a04422ee"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduce immunosuppression and observe is inappropriate because lowering immunosuppression worsens active rejection."
            },
            {
              "id": "B",
              "text": "Option B: Pulse glucocorticoids alone for presumed T-cell-mediated rejection is inappropriate because steroids alone do not adequately target circulating alloantibody."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous ganciclovir is inappropriate because ganciclovir treats CMV, not alloimmune microvascular injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduce immunosuppression and observe is inappropriate because lowering immunosuppression worsens active rejection."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulse glucocorticoids alone for presumed T-cell-mediated rejection is inappropriate because steroids alone do not adequately target circulating alloantibody."
            },
            {
              "id": "B",
              "text": "Option A: Reduce immunosuppression and observe is inappropriate because lowering immunosuppression worsens active rejection."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous ganciclovir is inappropriate because ganciclovir treats CMV, not alloimmune microvascular injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulse glucocorticoids alone for presumed T-cell-mediated rejection is inappropriate because steroids alone do not adequately target circulating alloantibody."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous ganciclovir is inappropriate because ganciclovir treats CMV, not alloimmune microvascular injury."
            },
            {
              "id": "B",
              "text": "Option A: Reduce immunosuppression and observe is inappropriate because lowering immunosuppression worsens active rejection."
            },
            {
              "id": "C",
              "text": "Option B: Pulse glucocorticoids alone for presumed T-cell-mediated rejection is inappropriate because steroids alone do not adequately target circulating alloantibody."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous ganciclovir is inappropriate because ganciclovir treats CMV, not alloimmune microvascular injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate transplant nephrectomy is inappropriate because nephrectomy is inappropriate before attempted graft salvage."
            },
            {
              "id": "B",
              "text": "Option A: Reduce immunosuppression and observe is inappropriate because lowering immunosuppression worsens active rejection."
            },
            {
              "id": "C",
              "text": "Option B: Pulse glucocorticoids alone for presumed T-cell-mediated rejection is inappropriate because steroids alone do not adequately target circulating alloantibody."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate transplant nephrectomy is inappropriate because nephrectomy is inappropriate before attempted graft salvage."
        }
      }
    },
    {
      "externalId": "d5-trauma-damage-control-resuscitation-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "3d10be78b59b6af1dadf42e41ba7c7399eaf2f3de8f30ce6d13dab33de7497c1",
        "ranaze_step3_prd": "3d10be78b59b6af1dadf42e41ba7c7399eaf2f3de8f30ce6d13dab33de7497c1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue packed red blood cells and large-volume normal saline until the hemoglobin exceeds 10 g/dL is inappropriate because red-cell-only and crystalloid-heavy resuscitation does not correct consumptive/dilutional coagulopathy and can aggravate hypothermia and acidosis."
            },
            {
              "id": "B",
              "text": "Option C: Pause transfusion until thromboelastography identifies each deficient component is inappropriate because viscoelastic testing can refine subsequent therapy, but an unstable patient with evident massive bleeding should receive empiric protocolized components immediately."
            },
            {
              "id": "C",
              "text": "Option D: Give recombinant factor VIIa as first-line therapy and defer plasma and platelets is inappropriate because recombinant factor VIIa is not first-line replacement for balanced component therapy and correction of temperature, calcium, fibrinogen, and acidosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue packed red blood cells and large-volume normal saline until the hemoglobin exceeds 10 g/dL is inappropriate because red-cell-only and crystalloid-heavy resuscitation does not correct consumptive/dilutional coagulopathy and can aggravate hypothermia and acidosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pause transfusion until thromboelastography identifies each deficient component is inappropriate because viscoelastic testing can refine subsequent therapy, but an unstable patient with evident massive bleeding should receive empiric protocolized components immediately."
            },
            {
              "id": "B",
              "text": "Option A: Continue packed red blood cells and large-volume normal saline until the hemoglobin exceeds 10 g/dL is inappropriate because red-cell-only and crystalloid-heavy resuscitation does not correct consumptive/dilutional coagulopathy and can aggravate hypothermia and acidosis."
            },
            {
              "id": "C",
              "text": "Option D: Give recombinant factor VIIa as first-line therapy and defer plasma and platelets is inappropriate because recombinant factor VIIa is not first-line replacement for balanced component therapy and correction of temperature, calcium, fibrinogen, and acidosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pause transfusion until thromboelastography identifies each deficient component is inappropriate because viscoelastic testing can refine subsequent therapy, but an unstable patient with evident massive bleeding should receive empiric protocolized components immediately."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give recombinant factor VIIa as first-line therapy and defer plasma and platelets is inappropriate because recombinant factor VIIa is not first-line replacement for balanced component therapy and correction of temperature, calcium, fibrinogen, and acidosis."
            },
            {
              "id": "B",
              "text": "Option A: Continue packed red blood cells and large-volume normal saline until the hemoglobin exceeds 10 g/dL is inappropriate because red-cell-only and crystalloid-heavy resuscitation does not correct consumptive/dilutional coagulopathy and can aggravate hypothermia and acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Pause transfusion until thromboelastography identifies each deficient component is inappropriate because viscoelastic testing can refine subsequent therapy, but an unstable patient with evident massive bleeding should receive empiric protocolized components immediately."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give recombinant factor VIIa as first-line therapy and defer plasma and platelets is inappropriate because recombinant factor VIIa is not first-line replacement for balanced component therapy and correction of temperature, calcium, fibrinogen, and acidosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give tranexamic acid only if bleeding continues beyond 3 hours after injury is inappropriate because tranexamic acid should be administered as early as possible and within 3 hours; delayed administration is not the indicated strategy."
            },
            {
              "id": "B",
              "text": "Option A: Continue packed red blood cells and large-volume normal saline until the hemoglobin exceeds 10 g/dL is inappropriate because red-cell-only and crystalloid-heavy resuscitation does not correct consumptive/dilutional coagulopathy and can aggravate hypothermia and acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Pause transfusion until thromboelastography identifies each deficient component is inappropriate because viscoelastic testing can refine subsequent therapy, but an unstable patient with evident massive bleeding should receive empiric protocolized components immediately."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give tranexamic acid only if bleeding continues beyond 3 hours after injury is inappropriate because tranexamic acid should be administered as early as possible and within 3 hours; delayed administration is not the indicated strategy."
        }
      }
    },
    {
      "externalId": "d5-trauma-grade3-btai-staged-tevar-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "ee2f21d2289458f478413fa188a285e042c38e1f1ad89f38142152dabbdf29c1",
        "ranaze_step3_prd": "ee2f21d2289458f478413fa188a285e042c38e1f1ad89f38142152dabbdf29c1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate open aortic repair before controlling the pelvic hemorrhage is inappropriate because open repair has greater morbidity than TEVAR and would inappropriately delay control of the active pelvic bleeding."
            },
            {
              "id": "B",
              "text": "Option C: Observe without heart-rate or blood-pressure control because the outer aortic contour is intact is inappropriate because an intact outer contour does not make a pseudoaneurysm benign; anti-impulse therapy and planned repair are still required."
            },
            {
              "id": "C",
              "text": "Option D: Begin therapeutic heparin and repeat CT angiography in 6 months is inappropriate because therapeutic anticoagulation does not treat the disrupted aortic wall and may worsen hemorrhage from associated injuries."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate open aortic repair before controlling the pelvic hemorrhage is inappropriate because open repair has greater morbidity than TEVAR and would inappropriately delay control of the active pelvic bleeding."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe without heart-rate or blood-pressure control because the outer aortic contour is intact is inappropriate because an intact outer contour does not make a pseudoaneurysm benign; anti-impulse therapy and planned repair are still required."
            },
            {
              "id": "B",
              "text": "Option B: Perform immediate open aortic repair before controlling the pelvic hemorrhage is inappropriate because open repair has greater morbidity than TEVAR and would inappropriately delay control of the active pelvic bleeding."
            },
            {
              "id": "C",
              "text": "Option D: Begin therapeutic heparin and repeat CT angiography in 6 months is inappropriate because therapeutic anticoagulation does not treat the disrupted aortic wall and may worsen hemorrhage from associated injuries."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe without heart-rate or blood-pressure control because the outer aortic contour is intact is inappropriate because an intact outer contour does not make a pseudoaneurysm benign; anti-impulse therapy and planned repair are still required."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin therapeutic heparin and repeat CT angiography in 6 months is inappropriate because therapeutic anticoagulation does not treat the disrupted aortic wall and may worsen hemorrhage from associated injuries."
            },
            {
              "id": "B",
              "text": "Option B: Perform immediate open aortic repair before controlling the pelvic hemorrhage is inappropriate because open repair has greater morbidity than TEVAR and would inappropriately delay control of the active pelvic bleeding."
            },
            {
              "id": "C",
              "text": "Option C: Observe without heart-rate or blood-pressure control because the outer aortic contour is intact is inappropriate because an intact outer contour does not make a pseudoaneurysm benign; anti-impulse therapy and planned repair are still required."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin therapeutic heparin and repeat CT angiography in 6 months is inappropriate because therapeutic anticoagulation does not treat the disrupted aortic wall and may worsen hemorrhage from associated injuries."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate thoracic endovascular repair solely because every grade 3 injury requires repair within 6 hours is inappropriate because grade 3 injury indicates repair, but a stable lesion without rupture signs can undergo delayed TEVAR after higher-priority injuries are addressed."
            },
            {
              "id": "B",
              "text": "Option B: Perform immediate open aortic repair before controlling the pelvic hemorrhage is inappropriate because open repair has greater morbidity than TEVAR and would inappropriately delay control of the active pelvic bleeding."
            },
            {
              "id": "C",
              "text": "Option C: Observe without heart-rate or blood-pressure control because the outer aortic contour is intact is inappropriate because an intact outer contour does not make a pseudoaneurysm benign; anti-impulse therapy and planned repair are still required."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate thoracic endovascular repair solely because every grade 3 injury requires repair within 6 hours is inappropriate because grade 3 injury indicates repair, but a stable lesion without rupture signs can undergo delayed TEVAR after higher-priority injuries are addressed."
        }
      }
    },
    {
      "externalId": "d5-trauma-resuscitative-thoracotomy-20260724",
      "expectedHashes": {
        "ranaze_step3_uat": "abba8d4440ae1ce5d8b7023d05213114b50d06c1e92370225cbc3a5277f4e015",
        "ranaze_step3_prd": "abba8d4440ae1ce5d8b7023d05213114b50d06c1e92370225cbc3a5277f4e015"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue closed-chest compressions for 20 minutes before considering an invasive procedure is inappropriate because closed compressions do not relieve tamponade or control intrathoracic exsanguination, and delay reduces the chance of neurologically intact survival."
            },
            {
              "id": "B",
              "text": "Option B: Perform needle pericardiocentesis and await the response is inappropriate because pericardiocentesis may fail with clotted hemopericardium and cannot provide definitive control of penetrating cardiac or hilar injury."
            },
            {
              "id": "C",
              "text": "Option C: Obtain CT angiography of the chest to localize the bleeding is inappropriate because a pulseless patient with qualifying signs of life cannot tolerate diagnostic imaging before resuscitative intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue closed-chest compressions for 20 minutes before considering an invasive procedure is inappropriate because closed compressions do not relieve tamponade or control intrathoracic exsanguination, and delay reduces the chance of neurologically intact survival."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform needle pericardiocentesis and await the response is inappropriate because pericardiocentesis may fail with clotted hemopericardium and cannot provide definitive control of penetrating cardiac or hilar injury."
            },
            {
              "id": "B",
              "text": "Option A: Continue closed-chest compressions for 20 minutes before considering an invasive procedure is inappropriate because closed compressions do not relieve tamponade or control intrathoracic exsanguination, and delay reduces the chance of neurologically intact survival."
            },
            {
              "id": "C",
              "text": "Option C: Obtain CT angiography of the chest to localize the bleeding is inappropriate because a pulseless patient with qualifying signs of life cannot tolerate diagnostic imaging before resuscitative intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform needle pericardiocentesis and await the response is inappropriate because pericardiocentesis may fail with clotted hemopericardium and cannot provide definitive control of penetrating cardiac or hilar injury."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain CT angiography of the chest to localize the bleeding is inappropriate because a pulseless patient with qualifying signs of life cannot tolerate diagnostic imaging before resuscitative intervention."
            },
            {
              "id": "B",
              "text": "Option A: Continue closed-chest compressions for 20 minutes before considering an invasive procedure is inappropriate because closed compressions do not relieve tamponade or control intrathoracic exsanguination, and delay reduces the chance of neurologically intact survival."
            },
            {
              "id": "C",
              "text": "Option B: Perform needle pericardiocentesis and await the response is inappropriate because pericardiocentesis may fail with clotted hemopericardium and cannot provide definitive control of penetrating cardiac or hilar injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain CT angiography of the chest to localize the bleeding is inappropriate because a pulseless patient with qualifying signs of life cannot tolerate diagnostic imaging before resuscitative intervention."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfer directly to the operating room before opening the chest is inappropriate because the patient is already pulseless; transfer before opening the chest creates an avoidable delay in correcting tamponade or exsanguination."
            },
            {
              "id": "B",
              "text": "Option A: Continue closed-chest compressions for 20 minutes before considering an invasive procedure is inappropriate because closed compressions do not relieve tamponade or control intrathoracic exsanguination, and delay reduces the chance of neurologically intact survival."
            },
            {
              "id": "C",
              "text": "Option B: Perform needle pericardiocentesis and await the response is inappropriate because pericardiocentesis may fail with clotted hemopericardium and cannot provide definitive control of penetrating cardiac or hilar injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfer directly to the operating room before opening the chest is inappropriate because the patient is already pulseless; transfer before opening the chest creates an avoidable delay in correcting tamponade or exsanguination."
        }
      }
    },
    {
      "externalId": "form7-s2-i001-beta-blocker-asthma",
      "expectedHashes": {
        "ranaze_step3_uat": "6facc2ac7ce7c5cf1233a1882a754436396511da4a63a4241936d404b3cc7c58",
        "ranaze_step3_prd": "6facc2ac7ce7c5cf1233a1882a754436396511da4a63a4241936d404b3cc7c58"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amitriptyline can be used for migraine prevention and is not specifically contraindicated by asthma."
            },
            {
              "id": "B",
              "text": "Option B: Cyproheptadine is sometimes used for migraine prevention, especially in younger patients, and does not carry the beta-blocker bronchospasm risk."
            },
            {
              "id": "C",
              "text": "Option C: Phenytoin is not a standard migraine-prevention drug, but asthma does not make it uniquely contraindicated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amitriptyline can be used for migraine prevention and is not specifically contraindicated by asthma."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cyproheptadine is sometimes used for migraine prevention, especially in younger patients, and does not carry the beta-blocker bronchospasm risk."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can be used for migraine prevention and is not specifically contraindicated by asthma."
            },
            {
              "id": "C",
              "text": "Option C: Phenytoin is not a standard migraine-prevention drug, but asthma does not make it uniquely contraindicated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cyproheptadine is sometimes used for migraine prevention, especially in younger patients, and does not carry the beta-blocker bronchospasm risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Phenytoin is not a standard migraine-prevention drug, but asthma does not make it uniquely contraindicated."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can be used for migraine prevention and is not specifically contraindicated by asthma."
            },
            {
              "id": "C",
              "text": "Option B: Cyproheptadine is sometimes used for migraine prevention, especially in younger patients, and does not carry the beta-blocker bronchospasm risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Phenytoin is not a standard migraine-prevention drug, but asthma does not make it uniquely contraindicated."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Verapamil is more commonly used for cluster headache than migraine prevention, but it is not specifically contraindicated because of asthma."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can be used for migraine prevention and is not specifically contraindicated by asthma."
            },
            {
              "id": "C",
              "text": "Option B: Cyproheptadine is sometimes used for migraine prevention, especially in younger patients, and does not carry the beta-blocker bronchospasm risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Verapamil is more commonly used for cluster headache than migraine prevention, but it is not specifically contraindicated because of asthma."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topiramate is an evidence-based migraine-prevention option and is not contraindicated by asthma."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can be used for migraine prevention and is not specifically contraindicated by asthma."
            },
            {
              "id": "C",
              "text": "Option B: Cyproheptadine is sometimes used for migraine prevention, especially in younger patients, and does not carry the beta-blocker bronchospasm risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topiramate is an evidence-based migraine-prevention option and is not contraindicated by asthma."
        }
      }
    },
    {
      "externalId": "form7-s2-i002-hfpef-diastolic",
      "expectedHashes": {
        "ranaze_step3_uat": "52c0ea8f45574611fd03f7ef71efd24b75d83b6806077c8b0dd9a7790917f8da",
        "ranaze_step3_prd": "52c0ea8f45574611fd03f7ef71efd24b75d83b6806077c8b0dd9a7790917f8da"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fixed obstruction to left ventricular outflow from severe calcific aortic stenosis is inappropriate because severe aortic stenosis can cause heart failure, but the echo does not show a major valvular lesion and the clinical picture fits hypertensive HFpEF."
            },
            {
              "id": "B",
              "text": "Option C: Acute papillary muscle dysfunction causing severe mitral regurgitation is inappropriate because acute severe mitral regurgitation would usually produce a different murmur pattern and not be the best explanation after echo showed preserved systolic function without major valve disease."
            },
            {
              "id": "C",
              "text": "Option D: Large pulmonary embolism causing acute right ventricular afterload increase is inappropriate because pulmonary embolism can cause dyspnea, but bibasilar crackles, pulmonary edema on imaging, and rapid response to diuresis support left-sided filling pressure elevation instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fixed obstruction to left ventricular outflow from severe calcific aortic stenosis is inappropriate because severe aortic stenosis can cause heart failure, but the echo does not show a major valvular lesion and the clinical picture fits hypertensive HFpEF."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute papillary muscle dysfunction causing severe mitral regurgitation is inappropriate because acute severe mitral regurgitation would usually produce a different murmur pattern and not be the best explanation after echo showed preserved systolic function without major valve disease."
            },
            {
              "id": "B",
              "text": "Option A: Fixed obstruction to left ventricular outflow from severe calcific aortic stenosis is inappropriate because severe aortic stenosis can cause heart failure, but the echo does not show a major valvular lesion and the clinical picture fits hypertensive HFpEF."
            },
            {
              "id": "C",
              "text": "Option D: Large pulmonary embolism causing acute right ventricular afterload increase is inappropriate because pulmonary embolism can cause dyspnea, but bibasilar crackles, pulmonary edema on imaging, and rapid response to diuresis support left-sided filling pressure elevation instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute papillary muscle dysfunction causing severe mitral regurgitation is inappropriate because acute severe mitral regurgitation would usually produce a different murmur pattern and not be the best explanation after echo showed preserved systolic function without major valve disease."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Large pulmonary embolism causing acute right ventricular afterload increase is inappropriate because pulmonary embolism can cause dyspnea, but bibasilar crackles, pulmonary edema on imaging, and rapid response to diuresis support left-sided filling pressure elevation instead."
            },
            {
              "id": "B",
              "text": "Option A: Fixed obstruction to left ventricular outflow from severe calcific aortic stenosis is inappropriate because severe aortic stenosis can cause heart failure, but the echo does not show a major valvular lesion and the clinical picture fits hypertensive HFpEF."
            },
            {
              "id": "C",
              "text": "Option C: Acute papillary muscle dysfunction causing severe mitral regurgitation is inappropriate because acute severe mitral regurgitation would usually produce a different murmur pattern and not be the best explanation after echo showed preserved systolic function without major valve disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Large pulmonary embolism causing acute right ventricular afterload increase is inappropriate because pulmonary embolism can cause dyspnea, but bibasilar crackles, pulmonary edema on imaging, and rapid response to diuresis support left-sided filling pressure elevation instead."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isolated right-sided pump failure from cor pulmonale is inappropriate because isolated right-sided failure causes systemic venous congestion rather than pulmonary edema from elevated left-sided pressures."
            },
            {
              "id": "B",
              "text": "Option A: Fixed obstruction to left ventricular outflow from severe calcific aortic stenosis is inappropriate because severe aortic stenosis can cause heart failure, but the echo does not show a major valvular lesion and the clinical picture fits hypertensive HFpEF."
            },
            {
              "id": "C",
              "text": "Option C: Acute papillary muscle dysfunction causing severe mitral regurgitation is inappropriate because acute severe mitral regurgitation would usually produce a different murmur pattern and not be the best explanation after echo showed preserved systolic function without major valve disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isolated right-sided pump failure from cor pulmonale is inappropriate because isolated right-sided failure causes systemic venous congestion rather than pulmonary edema from elevated left-sided pressures."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-output failure from chronic severe anemia is inappropriate because high-output failure requires a strong output-driving state such as severe anemia or thyrotoxicosis, which is not described here."
            },
            {
              "id": "B",
              "text": "Option A: Fixed obstruction to left ventricular outflow from severe calcific aortic stenosis is inappropriate because severe aortic stenosis can cause heart failure, but the echo does not show a major valvular lesion and the clinical picture fits hypertensive HFpEF."
            },
            {
              "id": "C",
              "text": "Option C: Acute papillary muscle dysfunction causing severe mitral regurgitation is inappropriate because acute severe mitral regurgitation would usually produce a different murmur pattern and not be the best explanation after echo showed preserved systolic function without major valve disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-output failure from chronic severe anemia is inappropriate because high-output failure requires a strong output-driving state such as severe anemia or thyrotoxicosis, which is not described here."
        }
      }
    },
    {
      "externalId": "form7-s2-i003-cap-mortality-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "0eecd42502bcff89f6115bab0f82cef97b429e8131b3d0f68e42cb4d8f833831",
        "ranaze_step3_prd": "0eecd42502bcff89f6115bab0f82cef97b429e8131b3d0f68e42cb4d8f833831"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diastolic blood pressure below 80 mm Hg is inappropriate because hypotension matters when systolic pressure is below 90 mm Hg or diastolic pressure is 60 mm Hg or lower, which is not present here."
            },
            {
              "id": "B",
              "text": "Option C: Female sex is inappropriate because sex is not a major independent bedside severity criterion in standard CAP mortality scores."
            },
            {
              "id": "C",
              "text": "Option D: Heart rate above 100/min is inappropriate because tachycardia can signal illness severity, but a pulse of 112/min is less weighty than age 76 in validated risk models."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diastolic blood pressure below 80 mm Hg is inappropriate because hypotension matters when systolic pressure is below 90 mm Hg or diastolic pressure is 60 mm Hg or lower, which is not present here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Female sex is inappropriate because sex is not a major independent bedside severity criterion in standard CAP mortality scores."
            },
            {
              "id": "B",
              "text": "Option B: Diastolic blood pressure below 80 mm Hg is inappropriate because hypotension matters when systolic pressure is below 90 mm Hg or diastolic pressure is 60 mm Hg or lower, which is not present here."
            },
            {
              "id": "C",
              "text": "Option D: Heart rate above 100/min is inappropriate because tachycardia can signal illness severity, but a pulse of 112/min is less weighty than age 76 in validated risk models."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Female sex is inappropriate because sex is not a major independent bedside severity criterion in standard CAP mortality scores."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Heart rate above 100/min is inappropriate because tachycardia can signal illness severity, but a pulse of 112/min is less weighty than age 76 in validated risk models."
            },
            {
              "id": "B",
              "text": "Option B: Diastolic blood pressure below 80 mm Hg is inappropriate because hypotension matters when systolic pressure is below 90 mm Hg or diastolic pressure is 60 mm Hg or lower, which is not present here."
            },
            {
              "id": "C",
              "text": "Option C: Female sex is inappropriate because sex is not a major independent bedside severity criterion in standard CAP mortality scores."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Heart rate above 100/min is inappropriate because tachycardia can signal illness severity, but a pulse of 112/min is less weighty than age 76 in validated risk models."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An oxygen saturation of 94% on room air does not by itself indicate severe CAP."
            },
            {
              "id": "B",
              "text": "Option B: Diastolic blood pressure below 80 mm Hg is inappropriate because hypotension matters when systolic pressure is below 90 mm Hg or diastolic pressure is 60 mm Hg or lower, which is not present here."
            },
            {
              "id": "C",
              "text": "Option C: Female sex is inappropriate because sex is not a major independent bedside severity criterion in standard CAP mortality scores."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An oxygen saturation of 94% on room air does not by itself indicate severe CAP."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Respiratory rate of 26/min is inappropriate because respiratory rate becomes a formal high-risk criterion at 30/min or greater, not 26/min."
            },
            {
              "id": "B",
              "text": "Option B: Diastolic blood pressure below 80 mm Hg is inappropriate because hypotension matters when systolic pressure is below 90 mm Hg or diastolic pressure is 60 mm Hg or lower, which is not present here."
            },
            {
              "id": "C",
              "text": "Option C: Female sex is inappropriate because sex is not a major independent bedside severity criterion in standard CAP mortality scores."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Respiratory rate of 26/min is inappropriate because respiratory rate becomes a formal high-risk criterion at 30/min or greater, not 26/min."
        }
      }
    },
    {
      "externalId": "form7-s2-i004-breaking-bad-news",
      "expectedHashes": {
        "ranaze_step3_uat": "3d3f845d76b7b785a0dcc43dcab6daf426330f8b4b6df7d6d35199790b71dcb0",
        "ranaze_step3_prd": "3d3f845d76b7b785a0dcc43dcab6daf426330f8b4b6df7d6d35199790b71dcb0"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022At least it is the least dangerous skin cancer. Let me explain what usually causes it.\u0022 is inappropriate because this response minimizes emotion and shifts too quickly into physician agenda and teaching."
            },
            {
              "id": "B",
              "text": "Option B: \u0022This is good news overall, but you still need another procedure, so try not to focus on the cancer label.\u0022 is inappropriate because this acknowledges some seriousness but still tells the patient how to feel and redirects away from his reaction."
            },
            {
              "id": "C",
              "text": "Option D: \u0022Basal cell carcinoma can be very aggressive, so we need to schedule a graft as soon as possible.\u0022 is inappropriate because calling basal cell carcinoma very aggressive is misleading and does not first address the patient\u0027s reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022At least it is the least dangerous skin cancer. Let me explain what usually causes it.\u0022 is inappropriate because this response minimizes emotion and shifts too quickly into physician agenda and teaching."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022This is good news overall, but you still need another procedure, so try not to focus on the cancer label.\u0022 is inappropriate because this acknowledges some seriousness but still tells the patient how to feel and redirects away from his reaction."
            },
            {
              "id": "B",
              "text": "Option A: \u0022At least it is the least dangerous skin cancer. Let me explain what usually causes it.\u0022 is inappropriate because this response minimizes emotion and shifts too quickly into physician agenda and teaching."
            },
            {
              "id": "C",
              "text": "Option D: \u0022Basal cell carcinoma can be very aggressive, so we need to schedule a graft as soon as possible.\u0022 is inappropriate because calling basal cell carcinoma very aggressive is misleading and does not first address the patient\u0027s reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022This is good news overall, but you still need another procedure, so try not to focus on the cancer label.\u0022 is inappropriate because this acknowledges some seriousness but still tells the patient how to feel and redirects away from his reaction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Basal cell carcinoma can be very aggressive, so we need to schedule a graft as soon as possible.\u0022 is inappropriate because calling basal cell carcinoma very aggressive is misleading and does not first address the patient\u0027s reaction."
            },
            {
              "id": "B",
              "text": "Option A: \u0022At least it is the least dangerous skin cancer. Let me explain what usually causes it.\u0022 is inappropriate because this response minimizes emotion and shifts too quickly into physician agenda and teaching."
            },
            {
              "id": "C",
              "text": "Option B: \u0022This is good news overall, but you still need another procedure, so try not to focus on the cancer label.\u0022 is inappropriate because this acknowledges some seriousness but still tells the patient how to feel and redirects away from his reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Basal cell carcinoma can be very aggressive, so we need to schedule a graft as soon as possible.\u0022 is inappropriate because calling basal cell carcinoma very aggressive is misleading and does not first address the patient\u0027s reaction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022You are fortunate. Your prognosis is much better than it would have been with melanoma.\u0022 is inappropriate because prognostic comparison may be true but is emotionally minimizing and not the best immediate response."
            },
            {
              "id": "B",
              "text": "Option A: \u0022At least it is the least dangerous skin cancer. Let me explain what usually causes it.\u0022 is inappropriate because this response minimizes emotion and shifts too quickly into physician agenda and teaching."
            },
            {
              "id": "C",
              "text": "Option B: \u0022This is good news overall, but you still need another procedure, so try not to focus on the cancer label.\u0022 is inappropriate because this acknowledges some seriousness but still tells the patient how to feel and redirects away from his reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022You are fortunate. Your prognosis is much better than it would have been with melanoma.\u0022 is inappropriate because prognostic comparison may be true but is emotionally minimizing and not the best immediate response."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I know this is upsetting, but the key point is that surgery should fix everything.\u0022 is inappropriate because premature reassurance can shut down discussion of distress and uncertainty."
            },
            {
              "id": "B",
              "text": "Option A: \u0022At least it is the least dangerous skin cancer. Let me explain what usually causes it.\u0022 is inappropriate because this response minimizes emotion and shifts too quickly into physician agenda and teaching."
            },
            {
              "id": "C",
              "text": "Option B: \u0022This is good news overall, but you still need another procedure, so try not to focus on the cancer label.\u0022 is inappropriate because this acknowledges some seriousness but still tells the patient how to feel and redirects away from his reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I know this is upsetting, but the key point is that surgery should fix everything.\u0022 is inappropriate because premature reassurance can shut down discussion of distress and uncertainty."
        }
      }
    },
    {
      "externalId": "form7-s2-i005-craniopharyngioma-hormones",
      "expectedHashes": {
        "ranaze_step3_uat": "937773946568221d924d8c63203ab5ab3522c1e1c43ffd321d48841bf96c5f0f",
        "ranaze_step3_prd": "937773946568221d924d8c63203ab5ab3522c1e1c43ffd321d48841bf96c5f0f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased ACTH, decreased LH, increased TSH, decreased prolactin is inappropriate because this pattern does not fit stalk compression and pituitary dysfunction from a suprasellar mass."
            },
            {
              "id": "B",
              "text": "Option B: Increased ACTH, increased LH, decreased TSH, increased prolactin is inappropriate because hyperprolactinemia can occur, but ACTH and LH would more likely fall, not rise, with pituitary compromise."
            },
            {
              "id": "C",
              "text": "Option D: Decreased ACTH, increased LH, increased TSH, decreased prolactin is inappropriate because low prolactin is not expected with stalk interruption, and gonadotropins would not rise appropriately."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased ACTH, decreased LH, increased TSH, decreased prolactin is inappropriate because this pattern does not fit stalk compression and pituitary dysfunction from a suprasellar mass."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased ACTH, increased LH, decreased TSH, increased prolactin is inappropriate because hyperprolactinemia can occur, but ACTH and LH would more likely fall, not rise, with pituitary compromise."
            },
            {
              "id": "B",
              "text": "Option A: Increased ACTH, decreased LH, increased TSH, decreased prolactin is inappropriate because this pattern does not fit stalk compression and pituitary dysfunction from a suprasellar mass."
            },
            {
              "id": "C",
              "text": "Option D: Decreased ACTH, increased LH, increased TSH, decreased prolactin is inappropriate because low prolactin is not expected with stalk interruption, and gonadotropins would not rise appropriately."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased ACTH, increased LH, decreased TSH, increased prolactin is inappropriate because hyperprolactinemia can occur, but ACTH and LH would more likely fall, not rise, with pituitary compromise."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decreased ACTH, increased LH, increased TSH, decreased prolactin is inappropriate because low prolactin is not expected with stalk interruption, and gonadotropins would not rise appropriately."
            },
            {
              "id": "B",
              "text": "Option A: Increased ACTH, decreased LH, increased TSH, decreased prolactin is inappropriate because this pattern does not fit stalk compression and pituitary dysfunction from a suprasellar mass."
            },
            {
              "id": "C",
              "text": "Option B: Increased ACTH, increased LH, decreased TSH, increased prolactin is inappropriate because hyperprolactinemia can occur, but ACTH and LH would more likely fall, not rise, with pituitary compromise."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decreased ACTH, increased LH, increased TSH, decreased prolactin is inappropriate because low prolactin is not expected with stalk interruption, and gonadotropins would not rise appropriately."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decreased ACTH, increased LH, decreased TSH, increased prolactin is inappropriate because an increased LH level is inconsistent with pituitary or stalk compression causing hypogonadism."
            },
            {
              "id": "B",
              "text": "Option A: Increased ACTH, decreased LH, increased TSH, decreased prolactin is inappropriate because this pattern does not fit stalk compression and pituitary dysfunction from a suprasellar mass."
            },
            {
              "id": "C",
              "text": "Option B: Increased ACTH, increased LH, decreased TSH, increased prolactin is inappropriate because hyperprolactinemia can occur, but ACTH and LH would more likely fall, not rise, with pituitary compromise."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decreased ACTH, increased LH, decreased TSH, increased prolactin is inappropriate because an increased LH level is inconsistent with pituitary or stalk compression causing hypogonadism."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased ACTH, decreased LH, decreased TSH, normal prolactin is inappropriate because normal prolactin is less likely than elevated prolactin with stalk effect, and ACTH would not be increased."
            },
            {
              "id": "B",
              "text": "Option A: Increased ACTH, decreased LH, increased TSH, decreased prolactin is inappropriate because this pattern does not fit stalk compression and pituitary dysfunction from a suprasellar mass."
            },
            {
              "id": "C",
              "text": "Option B: Increased ACTH, increased LH, decreased TSH, increased prolactin is inappropriate because hyperprolactinemia can occur, but ACTH and LH would more likely fall, not rise, with pituitary compromise."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased ACTH, decreased LH, decreased TSH, normal prolactin is inappropriate because normal prolactin is less likely than elevated prolactin with stalk effect, and ACTH would not be increased."
        }
      }
    },
    {
      "externalId": "form7-s2-i006-respiratory-sinus-arrhythmia",
      "expectedHashes": {
        "ranaze_step3_uat": "6c39cac0336e3e5d4de8f3945d1db852fff9af2678d28069e94d4ee04344ed00",
        "ranaze_step3_prd": "6c39cac0336e3e5d4de8f3945d1db852fff9af2678d28069e94d4ee04344ed00"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Conduction through an accessory atrioventricular pathway is inappropriate because an accessory pathway causes reentrant tachyarrhythmias, not a normal sinus rhythm that varies with respiration."
            },
            {
              "id": "B",
              "text": "Option C: Delayed ventricular repolarization from ion-channel dysfunction is inappropriate because delayed repolarization would affect QT duration and predispose to ventricular arrhythmias, not this benign pattern."
            },
            {
              "id": "C",
              "text": "Option D: Transient hypokalemia causing ectopy is inappropriate because electrolyte abnormalities may cause ectopy or conduction changes, not a normal inspiratory-expiratory sinus variation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Conduction through an accessory atrioventricular pathway is inappropriate because an accessory pathway causes reentrant tachyarrhythmias, not a normal sinus rhythm that varies with respiration."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delayed ventricular repolarization from ion-channel dysfunction is inappropriate because delayed repolarization would affect QT duration and predispose to ventricular arrhythmias, not this benign pattern."
            },
            {
              "id": "B",
              "text": "Option A: Conduction through an accessory atrioventricular pathway is inappropriate because an accessory pathway causes reentrant tachyarrhythmias, not a normal sinus rhythm that varies with respiration."
            },
            {
              "id": "C",
              "text": "Option D: Transient hypokalemia causing ectopy is inappropriate because electrolyte abnormalities may cause ectopy or conduction changes, not a normal inspiratory-expiratory sinus variation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delayed ventricular repolarization from ion-channel dysfunction is inappropriate because delayed repolarization would affect QT duration and predispose to ventricular arrhythmias, not this benign pattern."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transient hypokalemia causing ectopy is inappropriate because electrolyte abnormalities may cause ectopy or conduction changes, not a normal inspiratory-expiratory sinus variation."
            },
            {
              "id": "B",
              "text": "Option A: Conduction through an accessory atrioventricular pathway is inappropriate because an accessory pathway causes reentrant tachyarrhythmias, not a normal sinus rhythm that varies with respiration."
            },
            {
              "id": "C",
              "text": "Option C: Delayed ventricular repolarization from ion-channel dysfunction is inappropriate because delayed repolarization would affect QT duration and predispose to ventricular arrhythmias, not this benign pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transient hypokalemia causing ectopy is inappropriate because electrolyte abnormalities may cause ectopy or conduction changes, not a normal inspiratory-expiratory sinus variation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oscillation in arterial oxygen saturation during breathing is inappropriate because normal respiratory sinus arrhythmia is mediated primarily by autonomic tone, not by oxygen saturation swings in a healthy child."
            },
            {
              "id": "B",
              "text": "Option A: Conduction through an accessory atrioventricular pathway is inappropriate because an accessory pathway causes reentrant tachyarrhythmias, not a normal sinus rhythm that varies with respiration."
            },
            {
              "id": "C",
              "text": "Option C: Delayed ventricular repolarization from ion-channel dysfunction is inappropriate because delayed repolarization would affect QT duration and predispose to ventricular arrhythmias, not this benign pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oscillation in arterial oxygen saturation during breathing is inappropriate because normal respiratory sinus arrhythmia is mediated primarily by autonomic tone, not by oxygen saturation swings in a healthy child."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intermittent sinoatrial exit block is inappropriate because sinoatrial exit block would cause dropped impulses rather than smooth respiration-linked rate variation."
            },
            {
              "id": "B",
              "text": "Option A: Conduction through an accessory atrioventricular pathway is inappropriate because an accessory pathway causes reentrant tachyarrhythmias, not a normal sinus rhythm that varies with respiration."
            },
            {
              "id": "C",
              "text": "Option C: Delayed ventricular repolarization from ion-channel dysfunction is inappropriate because delayed repolarization would affect QT duration and predispose to ventricular arrhythmias, not this benign pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intermittent sinoatrial exit block is inappropriate because sinoatrial exit block would cause dropped impulses rather than smooth respiration-linked rate variation."
        }
      }
    },
    {
      "externalId": "form7-s2-i007-panic-agoraphobia-ssri",
      "expectedHashes": {
        "ranaze_step3_uat": "0cd95565a9d8f13233fe41b2e434c9c6b9ca4de66fd779bc12e2782d0cd31003",
        "ranaze_step3_prd": "0cd95565a9d8f13233fe41b2e434c9c6b9ca4de66fd779bc12e2782d0cd31003"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start bupropion and continue alprazolam at the current self-adjusted dose is inappropriate because bupropion is not a first-line agent for panic disorder and may worsen anxiety in some patients."
            },
            {
              "id": "B",
              "text": "Option B: Start buspirone and restrict alprazolam use to rescue dosing is inappropriate because buspirone is used for generalized anxiety disorder, not as first-line treatment for panic disorder with agoraphobia."
            },
            {
              "id": "C",
              "text": "Option C: Switch alprazolam to clonazepam monotherapy is inappropriate because switching to another benzodiazepine does not address first-line long-term treatment and is risky in a patient with substance use history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start bupropion and continue alprazolam at the current self-adjusted dose is inappropriate because bupropion is not a first-line agent for panic disorder and may worsen anxiety in some patients."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start buspirone and restrict alprazolam use to rescue dosing is inappropriate because buspirone is used for generalized anxiety disorder, not as first-line treatment for panic disorder with agoraphobia."
            },
            {
              "id": "B",
              "text": "Option A: Start bupropion and continue alprazolam at the current self-adjusted dose is inappropriate because bupropion is not a first-line agent for panic disorder and may worsen anxiety in some patients."
            },
            {
              "id": "C",
              "text": "Option C: Switch alprazolam to clonazepam monotherapy is inappropriate because switching to another benzodiazepine does not address first-line long-term treatment and is risky in a patient with substance use history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start buspirone and restrict alprazolam use to rescue dosing is inappropriate because buspirone is used for generalized anxiety disorder, not as first-line treatment for panic disorder with agoraphobia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Switch alprazolam to clonazepam monotherapy is inappropriate because switching to another benzodiazepine does not address first-line long-term treatment and is risky in a patient with substance use history."
            },
            {
              "id": "B",
              "text": "Option A: Start bupropion and continue alprazolam at the current self-adjusted dose is inappropriate because bupropion is not a first-line agent for panic disorder and may worsen anxiety in some patients."
            },
            {
              "id": "C",
              "text": "Option B: Start buspirone and restrict alprazolam use to rescue dosing is inappropriate because buspirone is used for generalized anxiety disorder, not as first-line treatment for panic disorder with agoraphobia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Switch alprazolam to clonazepam monotherapy is inappropriate because switching to another benzodiazepine does not address first-line long-term treatment and is risky in a patient with substance use history."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop alprazolam immediately and begin propranolol is inappropriate because abrupt discontinuation of alprazolam risks withdrawal, and propranolol is not primary therapy for panic disorder."
            },
            {
              "id": "B",
              "text": "Option A: Start bupropion and continue alprazolam at the current self-adjusted dose is inappropriate because bupropion is not a first-line agent for panic disorder and may worsen anxiety in some patients."
            },
            {
              "id": "C",
              "text": "Option B: Start buspirone and restrict alprazolam use to rescue dosing is inappropriate because buspirone is used for generalized anxiety disorder, not as first-line treatment for panic disorder with agoraphobia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop alprazolam immediately and begin propranolol is inappropriate because abrupt discontinuation of alprazolam risks withdrawal, and propranolol is not primary therapy for panic disorder."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue alprazolam alone and add hydroxyzine as needed is inappropriate because continuing benzodiazepine-centered treatment ignores the preferred SSRI-based strategy."
            },
            {
              "id": "B",
              "text": "Option A: Start bupropion and continue alprazolam at the current self-adjusted dose is inappropriate because bupropion is not a first-line agent for panic disorder and may worsen anxiety in some patients."
            },
            {
              "id": "C",
              "text": "Option B: Start buspirone and restrict alprazolam use to rescue dosing is inappropriate because buspirone is used for generalized anxiety disorder, not as first-line treatment for panic disorder with agoraphobia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue alprazolam alone and add hydroxyzine as needed is inappropriate because continuing benzodiazepine-centered treatment ignores the preferred SSRI-based strategy."
        }
      }
    },
    {
      "externalId": "form7-s2-i009-hyperthyroidism-afib",
      "expectedHashes": {
        "ranaze_step3_uat": "b9c2a2254df2f48d774c103f8e02b06b099ca96df65ad61183a0053ddbbe9a8f",
        "ranaze_step3_prd": "b9c2a2254df2f48d774c103f8e02b06b099ca96df65ad61183a0053ddbbe9a8f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Coarctation of the aorta is inappropriate because coarctation presents much earlier and would not explain weight loss, bowel hypermotility, and atrial fibrillation."
            },
            {
              "id": "B",
              "text": "Option B: Cushing syndrome usually causes weight gain, skin changes, proximal weakness, and glucose intolerance rather than this hypermetabolic picture."
            },
            {
              "id": "C",
              "text": "Option D: Pheochromocytoma causes paroxysmal headache, diaphoresis, and palpitations, not the full hyperthyroid syndrome described."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Coarctation of the aorta is inappropriate because coarctation presents much earlier and would not explain weight loss, bowel hypermotility, and atrial fibrillation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cushing syndrome usually causes weight gain, skin changes, proximal weakness, and glucose intolerance rather than this hypermetabolic picture."
            },
            {
              "id": "B",
              "text": "Option A: Coarctation of the aorta is inappropriate because coarctation presents much earlier and would not explain weight loss, bowel hypermotility, and atrial fibrillation."
            },
            {
              "id": "C",
              "text": "Option D: Pheochromocytoma causes paroxysmal headache, diaphoresis, and palpitations, not the full hyperthyroid syndrome described."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cushing syndrome usually causes weight gain, skin changes, proximal weakness, and glucose intolerance rather than this hypermetabolic picture."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pheochromocytoma causes paroxysmal headache, diaphoresis, and palpitations, not the full hyperthyroid syndrome described."
            },
            {
              "id": "B",
              "text": "Option A: Coarctation of the aorta is inappropriate because coarctation presents much earlier and would not explain weight loss, bowel hypermotility, and atrial fibrillation."
            },
            {
              "id": "C",
              "text": "Option B: Cushing syndrome usually causes weight gain, skin changes, proximal weakness, and glucose intolerance rather than this hypermetabolic picture."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pheochromocytoma causes paroxysmal headache, diaphoresis, and palpitations, not the full hyperthyroid syndrome described."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Renal artery stenosis can worsen hypertension but does not explain atrial fibrillation with weight loss and frequent bowel movements."
            },
            {
              "id": "B",
              "text": "Option A: Coarctation of the aorta is inappropriate because coarctation presents much earlier and would not explain weight loss, bowel hypermotility, and atrial fibrillation."
            },
            {
              "id": "C",
              "text": "Option B: Cushing syndrome usually causes weight gain, skin changes, proximal weakness, and glucose intolerance rather than this hypermetabolic picture."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Renal artery stenosis can worsen hypertension but does not explain atrial fibrillation with weight loss and frequent bowel movements."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Primary hyperaldosteronism causes hypertension and hypokalemia-related symptoms, not weight loss and bowel hypermotility."
            },
            {
              "id": "B",
              "text": "Option A: Coarctation of the aorta is inappropriate because coarctation presents much earlier and would not explain weight loss, bowel hypermotility, and atrial fibrillation."
            },
            {
              "id": "C",
              "text": "Option B: Cushing syndrome usually causes weight gain, skin changes, proximal weakness, and glucose intolerance rather than this hypermetabolic picture."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Primary hyperaldosteronism causes hypertension and hypokalemia-related symptoms, not weight loss and bowel hypermotility."
        }
      }
    },
    {
      "externalId": "form7-s2-i010-chronic-mesenteric-ischemia",
      "expectedHashes": {
        "ranaze_step3_uat": "3d6926b8661e594c43157d29623513cde00e6646f16f9a6c1de02de7f3f722a4",
        "ranaze_step3_prd": "3d6926b8661e594c43157d29623513cde00e6646f16f9a6c1de02de7f3f722a4"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspirin-induced colitis is inappropriate because aspirin can cause mucosal injury, but it does not explain classic postprandial pain with food avoidance and major weight loss."
            },
            {
              "id": "B",
              "text": "Option B: Right-sided colon adenocarcinoma is inappropriate because colon cancer may cause occult bleeding and weight loss, but severe meal-triggered pain with fear of eating is more typical of mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Irritable bowel syndrome does not cause occult blood or significant weight loss in an older adult."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspirin-induced colitis is inappropriate because aspirin can cause mucosal injury, but it does not explain classic postprandial pain with food avoidance and major weight loss."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Right-sided colon adenocarcinoma is inappropriate because colon cancer may cause occult bleeding and weight loss, but severe meal-triggered pain with fear of eating is more typical of mesenteric ischemia."
            },
            {
              "id": "B",
              "text": "Option A: Aspirin-induced colitis is inappropriate because aspirin can cause mucosal injury, but it does not explain classic postprandial pain with food avoidance and major weight loss."
            },
            {
              "id": "C",
              "text": "Option C: Irritable bowel syndrome does not cause occult blood or significant weight loss in an older adult."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Right-sided colon adenocarcinoma is inappropriate because colon cancer may cause occult bleeding and weight loss, but severe meal-triggered pain with fear of eating is more typical of mesenteric ischemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Irritable bowel syndrome does not cause occult blood or significant weight loss in an older adult."
            },
            {
              "id": "B",
              "text": "Option A: Aspirin-induced colitis is inappropriate because aspirin can cause mucosal injury, but it does not explain classic postprandial pain with food avoidance and major weight loss."
            },
            {
              "id": "C",
              "text": "Option B: Right-sided colon adenocarcinoma is inappropriate because colon cancer may cause occult bleeding and weight loss, but severe meal-triggered pain with fear of eating is more typical of mesenteric ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Irritable bowel syndrome does not cause occult blood or significant weight loss in an older adult."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ulcerative colitis usually causes chronic inflammatory diarrhea with rectal bleeding, not isolated postprandial ischemic pain in this age group."
            },
            {
              "id": "B",
              "text": "Option A: Aspirin-induced colitis is inappropriate because aspirin can cause mucosal injury, but it does not explain classic postprandial pain with food avoidance and major weight loss."
            },
            {
              "id": "C",
              "text": "Option B: Right-sided colon adenocarcinoma is inappropriate because colon cancer may cause occult bleeding and weight loss, but severe meal-triggered pain with fear of eating is more typical of mesenteric ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ulcerative colitis usually causes chronic inflammatory diarrhea with rectal bleeding, not isolated postprandial ischemic pain in this age group."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic pancreatitis more often causes epigastric pain radiating to the back, steatorrhea, and risk factors such as alcohol use."
            },
            {
              "id": "B",
              "text": "Option A: Aspirin-induced colitis is inappropriate because aspirin can cause mucosal injury, but it does not explain classic postprandial pain with food avoidance and major weight loss."
            },
            {
              "id": "C",
              "text": "Option B: Right-sided colon adenocarcinoma is inappropriate because colon cancer may cause occult bleeding and weight loss, but severe meal-triggered pain with fear of eating is more typical of mesenteric ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic pancreatitis more often causes epigastric pain radiating to the back, steatorrhea, and risk factors such as alcohol use."
        }
      }
    },
    {
      "externalId": "form7-s2-i011-splenic-sequestration",
      "expectedHashes": {
        "ranaze_step3_uat": "09e0a91455de47269b89b9b59248bc1f8d1c810701c62f164df9a9c7ecf5ac64",
        "ranaze_step3_prd": "09e0a91455de47269b89b9b59248bc1f8d1c810701c62f164df9a9c7ecf5ac64"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Crackles with a new focal infiltrate at the right lung base is inappropriate because acute chest syndrome usually presents with fever, respiratory symptoms, hypoxemia, and a new infiltrate."
            },
            {
              "id": "B",
              "text": "Option B: Exudative pharyngitis with tender anterior cervical lymphadenopathy is inappropriate because pharyngitis does not explain the profound acute anemia and thrombocytopenia."
            },
            {
              "id": "C",
              "text": "Option C: Purulent bilateral conjunctivitis is inappropriate because conjunctivitis is unrelated to this sickle cell emergency pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Crackles with a new focal infiltrate at the right lung base is inappropriate because acute chest syndrome usually presents with fever, respiratory symptoms, hypoxemia, and a new infiltrate."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exudative pharyngitis with tender anterior cervical lymphadenopathy is inappropriate because pharyngitis does not explain the profound acute anemia and thrombocytopenia."
            },
            {
              "id": "B",
              "text": "Option A: Crackles with a new focal infiltrate at the right lung base is inappropriate because acute chest syndrome usually presents with fever, respiratory symptoms, hypoxemia, and a new infiltrate."
            },
            {
              "id": "C",
              "text": "Option C: Purulent bilateral conjunctivitis is inappropriate because conjunctivitis is unrelated to this sickle cell emergency pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exudative pharyngitis with tender anterior cervical lymphadenopathy is inappropriate because pharyngitis does not explain the profound acute anemia and thrombocytopenia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Purulent bilateral conjunctivitis is inappropriate because conjunctivitis is unrelated to this sickle cell emergency pattern."
            },
            {
              "id": "B",
              "text": "Option A: Crackles with a new focal infiltrate at the right lung base is inappropriate because acute chest syndrome usually presents with fever, respiratory symptoms, hypoxemia, and a new infiltrate."
            },
            {
              "id": "C",
              "text": "Option B: Exudative pharyngitis with tender anterior cervical lymphadenopathy is inappropriate because pharyngitis does not explain the profound acute anemia and thrombocytopenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Purulent bilateral conjunctivitis is inappropriate because conjunctivitis is unrelated to this sickle cell emergency pattern."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Painful swelling of both hands and feet is inappropriate because dactylitis is common in young children with sickle cell disease but would not explain this severe acute anemia with thrombocytopenia."
            },
            {
              "id": "B",
              "text": "Option A: Crackles with a new focal infiltrate at the right lung base is inappropriate because acute chest syndrome usually presents with fever, respiratory symptoms, hypoxemia, and a new infiltrate."
            },
            {
              "id": "C",
              "text": "Option B: Exudative pharyngitis with tender anterior cervical lymphadenopathy is inappropriate because pharyngitis does not explain the profound acute anemia and thrombocytopenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Painful swelling of both hands and feet is inappropriate because dactylitis is common in young children with sickle cell disease but would not explain this severe acute anemia with thrombocytopenia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A new loud holosystolic murmur at the apex is inappropriate because a flow murmur can occur with anemia, but the key expected finding is splenic enlargement."
            },
            {
              "id": "B",
              "text": "Option A: Crackles with a new focal infiltrate at the right lung base is inappropriate because acute chest syndrome usually presents with fever, respiratory symptoms, hypoxemia, and a new infiltrate."
            },
            {
              "id": "C",
              "text": "Option B: Exudative pharyngitis with tender anterior cervical lymphadenopathy is inappropriate because pharyngitis does not explain the profound acute anemia and thrombocytopenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A new loud holosystolic murmur at the apex is inappropriate because a flow murmur can occur with anemia, but the key expected finding is splenic enlargement."
        }
      }
    },
    {
      "externalId": "form7-s2-i012-screening-prevalence-ppv",
      "expectedHashes": {
        "ranaze_step3_uat": "269b90e7922139e315af1388d889da27d043c4916c9cac0cb094071cf2f1cd88",
        "ranaze_step3_prd": "269b90e7922139e315af1388d889da27d043c4916c9cac0cb094071cf2f1cd88"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decrease the negative predictive value is inappropriate because negative predictive value usually increases, not decreases, when prevalence falls."
            },
            {
              "id": "B",
              "text": "Option B: Decrease the specificity is inappropriate because specificity does not inherently decline just because the tested population changes to lower prevalence."
            },
            {
              "id": "C",
              "text": "Option D: Increase the sensitivity is inappropriate because sensitivity is a test property and does not increase because the test is applied more broadly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decrease the negative predictive value is inappropriate because negative predictive value usually increases, not decreases, when prevalence falls."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decrease the specificity is inappropriate because specificity does not inherently decline just because the tested population changes to lower prevalence."
            },
            {
              "id": "B",
              "text": "Option A: Decrease the negative predictive value is inappropriate because negative predictive value usually increases, not decreases, when prevalence falls."
            },
            {
              "id": "C",
              "text": "Option D: Increase the sensitivity is inappropriate because sensitivity is a test property and does not increase because the test is applied more broadly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decrease the specificity is inappropriate because specificity does not inherently decline just because the tested population changes to lower prevalence."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase the sensitivity is inappropriate because sensitivity is a test property and does not increase because the test is applied more broadly."
            },
            {
              "id": "B",
              "text": "Option A: Decrease the negative predictive value is inappropriate because negative predictive value usually increases, not decreases, when prevalence falls."
            },
            {
              "id": "C",
              "text": "Option B: Decrease the specificity is inappropriate because specificity does not inherently decline just because the tested population changes to lower prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase the sensitivity is inappropriate because sensitivity is a test property and does not increase because the test is applied more broadly."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase the positive predictive value is inappropriate because positive predictive value decreases as prevalence decreases."
            },
            {
              "id": "B",
              "text": "Option A: Decrease the negative predictive value is inappropriate because negative predictive value usually increases, not decreases, when prevalence falls."
            },
            {
              "id": "C",
              "text": "Option B: Decrease the specificity is inappropriate because specificity does not inherently decline just because the tested population changes to lower prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase the positive predictive value is inappropriate because positive predictive value decreases as prevalence decreases."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Broader use may worsen some biases but does not eliminate spectrum bias."
            },
            {
              "id": "B",
              "text": "Option A: Decrease the negative predictive value is inappropriate because negative predictive value usually increases, not decreases, when prevalence falls."
            },
            {
              "id": "C",
              "text": "Option B: Decrease the specificity is inappropriate because specificity does not inherently decline just because the tested population changes to lower prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Broader use may worsen some biases but does not eliminate spectrum bias."
        }
      }
    },
    {
      "externalId": "form7-s2-i013-depression-open-ended-response",
      "expectedHashes": {
        "ranaze_step3_uat": "70b72cb2c375ea88032b47b3bc6251250585e6423c848f6dab618739c807a78d",
        "ranaze_step3_prd": "70b72cb2c375ea88032b47b3bc6251250585e6423c848f6dab618739c807a78d"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Would you be willing to restart medication? Which adverse effects worry you most this time?\u0022 is inappropriate because medication discussion is important, but it moves too quickly to treatment before exploring the patient\u0027s meaning and efforts."
            },
            {
              "id": "B",
              "text": "Option B: \u0022Sometimes this just happens, and it may not have been preventable.\u0022 is inappropriate because this may be partly true but is somewhat distancing and closes exploration."
            },
            {
              "id": "C",
              "text": "Option C: \u0022That sounds like the depression speaking, so try not to blame yourself.\u0022 is inappropriate because it is interpretive and paternalistic; the physician should first elicit the patient\u0027s own perspective."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Would you be willing to restart medication? Which adverse effects worry you most this time?\u0022 is inappropriate because medication discussion is important, but it moves too quickly to treatment before exploring the patient\u0027s meaning and efforts."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Sometimes this just happens, and it may not have been preventable.\u0022 is inappropriate because this may be partly true but is somewhat distancing and closes exploration."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Would you be willing to restart medication? Which adverse effects worry you most this time?\u0022 is inappropriate because medication discussion is important, but it moves too quickly to treatment before exploring the patient\u0027s meaning and efforts."
            },
            {
              "id": "C",
              "text": "Option C: \u0022That sounds like the depression speaking, so try not to blame yourself.\u0022 is inappropriate because it is interpretive and paternalistic; the physician should first elicit the patient\u0027s own perspective."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Sometimes this just happens, and it may not have been preventable.\u0022 is inappropriate because this may be partly true but is somewhat distancing and closes exploration."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022That sounds like the depression speaking, so try not to blame yourself.\u0022 is inappropriate because it is interpretive and paternalistic; the physician should first elicit the patient\u0027s own perspective."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Would you be willing to restart medication? Which adverse effects worry you most this time?\u0022 is inappropriate because medication discussion is important, but it moves too quickly to treatment before exploring the patient\u0027s meaning and efforts."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Sometimes this just happens, and it may not have been preventable.\u0022 is inappropriate because this may be partly true but is somewhat distancing and closes exploration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022That sounds like the depression speaking, so try not to blame yourself.\u0022 is inappropriate because it is interpretive and paternalistic; the physician should first elicit the patient\u0027s own perspective."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Because depression is chronic, you will need medication for the rest of your life.\u0022 is inappropriate because this is overly absolute and not appropriate at this stage of the conversation."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Would you be willing to restart medication? Which adverse effects worry you most this time?\u0022 is inappropriate because medication discussion is important, but it moves too quickly to treatment before exploring the patient\u0027s meaning and efforts."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Sometimes this just happens, and it may not have been preventable.\u0022 is inappropriate because this may be partly true but is somewhat distancing and closes exploration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Because depression is chronic, you will need medication for the rest of your life.\u0022 is inappropriate because this is overly absolute and not appropriate at this stage of the conversation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Your recurrence means we should focus on treatment instead of on why it happened.\u0022 is inappropriate because redirecting away from the patient\u0027s concern misses an opportunity to deepen understanding and rapport."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Would you be willing to restart medication? Which adverse effects worry you most this time?\u0022 is inappropriate because medication discussion is important, but it moves too quickly to treatment before exploring the patient\u0027s meaning and efforts."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Sometimes this just happens, and it may not have been preventable.\u0022 is inappropriate because this may be partly true but is somewhat distancing and closes exploration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Your recurrence means we should focus on treatment instead of on why it happened.\u0022 is inappropriate because redirecting away from the patient\u0027s concern misses an opportunity to deepen understanding and rapport."
        }
      }
    },
    {
      "externalId": "form7-s2-i014-left-ventricular-aneurysm-cxr",
      "expectedHashes": {
        "ranaze_step3_uat": "a89e1bba3b1e65aa3dabcd202c88df20be469348eac24e843fac796888fb806e",
        "ranaze_step3_prd": "a89e1bba3b1e65aa3dabcd202c88df20be469348eac24e843fac796888fb806e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continuous diaphragm sign suggests pneumomediastinum or pneumopericardium, not ventricular aneurysm."
            },
            {
              "id": "B",
              "text": "Option C: Deep sulcus sign is associated with pneumothorax on supine films."
            },
            {
              "id": "C",
              "text": "Option D: Elevated left hemidiaphragm from subphrenic pathology is inappropriate because an elevated hemidiaphragm would not be the expected consequence of a ventricular aneurysm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continuous diaphragm sign suggests pneumomediastinum or pneumopericardium, not ventricular aneurysm."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Deep sulcus sign is associated with pneumothorax on supine films."
            },
            {
              "id": "B",
              "text": "Option B: Continuous diaphragm sign suggests pneumomediastinum or pneumopericardium, not ventricular aneurysm."
            },
            {
              "id": "C",
              "text": "Option D: Elevated left hemidiaphragm from subphrenic pathology is inappropriate because an elevated hemidiaphragm would not be the expected consequence of a ventricular aneurysm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Deep sulcus sign is associated with pneumothorax on supine films."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elevated left hemidiaphragm from subphrenic pathology is inappropriate because an elevated hemidiaphragm would not be the expected consequence of a ventricular aneurysm."
            },
            {
              "id": "B",
              "text": "Option B: Continuous diaphragm sign suggests pneumomediastinum or pneumopericardium, not ventricular aneurysm."
            },
            {
              "id": "C",
              "text": "Option C: Deep sulcus sign is associated with pneumothorax on supine films."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elevated left hemidiaphragm from subphrenic pathology is inappropriate because an elevated hemidiaphragm would not be the expected consequence of a ventricular aneurysm."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inferior rib notching is inappropriate because rib notching suggests long-standing coarctation of the aorta."
            },
            {
              "id": "B",
              "text": "Option B: Continuous diaphragm sign suggests pneumomediastinum or pneumopericardium, not ventricular aneurysm."
            },
            {
              "id": "C",
              "text": "Option C: Deep sulcus sign is associated with pneumothorax on supine films."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inferior rib notching is inappropriate because rib notching suggests long-standing coarctation of the aorta."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bilateral hilar cavitary lesions is inappropriate because cavitary hilar lesions suggest destructive infection or malignancy, not postinfarction ventricular remodeling."
            },
            {
              "id": "B",
              "text": "Option B: Continuous diaphragm sign suggests pneumomediastinum or pneumopericardium, not ventricular aneurysm."
            },
            {
              "id": "C",
              "text": "Option C: Deep sulcus sign is associated with pneumothorax on supine films."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bilateral hilar cavitary lesions is inappropriate because cavitary hilar lesions suggest destructive infection or malignancy, not postinfarction ventricular remodeling."
        }
      }
    },
    {
      "externalId": "form7-s2-i015-acrosome-head",
      "expectedHashes": {
        "ranaze_step3_uat": "85610c3434e3ea653fe17c7c68ca9bf3348fd83cb9699a98521de6cc490b37c4",
        "ranaze_step3_prd": "85610c3434e3ea653fe17c7c68ca9bf3348fd83cb9699a98521de6cc490b37c4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The midpiece contains mitochondria that power motility, not the acrosomal enzymes involved in zona penetration."
            },
            {
              "id": "B",
              "text": "Option C: The neck links the head to the flagellum but is not where acrosomal contents are exposed."
            },
            {
              "id": "C",
              "text": "Option D: The tail is responsible for motility and does not house the acrosome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The midpiece contains mitochondria that power motility, not the acrosomal enzymes involved in zona penetration."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The neck links the head to the flagellum but is not where acrosomal contents are exposed."
            },
            {
              "id": "B",
              "text": "Option B: The midpiece contains mitochondria that power motility, not the acrosomal enzymes involved in zona penetration."
            },
            {
              "id": "C",
              "text": "Option D: The tail is responsible for motility and does not house the acrosome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The neck links the head to the flagellum but is not where acrosomal contents are exposed."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The tail is responsible for motility and does not house the acrosome."
            },
            {
              "id": "B",
              "text": "Option B: The midpiece contains mitochondria that power motility, not the acrosomal enzymes involved in zona penetration."
            },
            {
              "id": "C",
              "text": "Option C: The neck links the head to the flagellum but is not where acrosomal contents are exposed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The tail is responsible for motility and does not house the acrosome."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The annulus is part of the junctional structure between midpiece and principal piece, not the acrosomal region."
            },
            {
              "id": "B",
              "text": "Option B: The midpiece contains mitochondria that power motility, not the acrosomal enzymes involved in zona penetration."
            },
            {
              "id": "C",
              "text": "Option C: The neck links the head to the flagellum but is not where acrosomal contents are exposed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The annulus is part of the junctional structure between midpiece and principal piece, not the acrosomal region."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The principal piece sheath belongs to the flagellum and is unrelated to the acrosome reaction."
            },
            {
              "id": "B",
              "text": "Option B: The midpiece contains mitochondria that power motility, not the acrosomal enzymes involved in zona penetration."
            },
            {
              "id": "C",
              "text": "Option C: The neck links the head to the flagellum but is not where acrosomal contents are exposed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The principal piece sheath belongs to the flagellum and is unrelated to the acrosome reaction."
        }
      }
    },
    {
      "externalId": "form7-s2-i016-lithium-pregnancy",
      "expectedHashes": {
        "ranaze_step3_uat": "76127482f3a53c91848ed03f486d9dd6abbb59f4b54f5c5b77d9b7bf5a06a874",
        "ranaze_step3_prd": "76127482f3a53c91848ed03f486d9dd6abbb59f4b54f5c5b77d9b7bf5a06a874"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decrease the lithium dose by half now to reduce teratogenic risk is inappropriate because empiric halving of the dose risks relapse and does not reflect individualized lithium level monitoring."
            },
            {
              "id": "B",
              "text": "Option B: Stop lithium immediately and observe closely is inappropriate because abrupt discontinuation can precipitate bipolar relapse and is not routinely recommended in a stable patient for whom lithium has been effective."
            },
            {
              "id": "C",
              "text": "Option C: Continue lithium now but switch to carbamazepine before breastfeeding is inappropriate because carbamazepine is not a preferred substitution to facilitate breastfeeding and carries teratogenic risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decrease the lithium dose by half now to reduce teratogenic risk is inappropriate because empiric halving of the dose risks relapse and does not reflect individualized lithium level monitoring."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop lithium immediately and observe closely is inappropriate because abrupt discontinuation can precipitate bipolar relapse and is not routinely recommended in a stable patient for whom lithium has been effective."
            },
            {
              "id": "B",
              "text": "Option A: Decrease the lithium dose by half now to reduce teratogenic risk is inappropriate because empiric halving of the dose risks relapse and does not reflect individualized lithium level monitoring."
            },
            {
              "id": "C",
              "text": "Option C: Continue lithium now but switch to carbamazepine before breastfeeding is inappropriate because carbamazepine is not a preferred substitution to facilitate breastfeeding and carries teratogenic risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop lithium immediately and observe closely is inappropriate because abrupt discontinuation can precipitate bipolar relapse and is not routinely recommended in a stable patient for whom lithium has been effective."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue lithium now but switch to carbamazepine before breastfeeding is inappropriate because carbamazepine is not a preferred substitution to facilitate breastfeeding and carries teratogenic risk."
            },
            {
              "id": "B",
              "text": "Option A: Decrease the lithium dose by half now to reduce teratogenic risk is inappropriate because empiric halving of the dose risks relapse and does not reflect individualized lithium level monitoring."
            },
            {
              "id": "C",
              "text": "Option B: Stop lithium immediately and observe closely is inappropriate because abrupt discontinuation can precipitate bipolar relapse and is not routinely recommended in a stable patient for whom lithium has been effective."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue lithium now but switch to carbamazepine before breastfeeding is inappropriate because carbamazepine is not a preferred substitution to facilitate breastfeeding and carries teratogenic risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Replace lithium with valproic acid for the rest of pregnancy is inappropriate because valproic acid is generally avoided in pregnancy because of substantial teratogenic and neurodevelopmental risk."
            },
            {
              "id": "B",
              "text": "Option A: Decrease the lithium dose by half now to reduce teratogenic risk is inappropriate because empiric halving of the dose risks relapse and does not reflect individualized lithium level monitoring."
            },
            {
              "id": "C",
              "text": "Option B: Stop lithium immediately and observe closely is inappropriate because abrupt discontinuation can precipitate bipolar relapse and is not routinely recommended in a stable patient for whom lithium has been effective."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Replace lithium with valproic acid for the rest of pregnancy is inappropriate because valproic acid is generally avoided in pregnancy because of substantial teratogenic and neurodevelopmental risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Switch from lithium to sertraline in the third trimester is inappropriate because sertraline is not a substitute mood stabilizer for bipolar disorder maintenance."
            },
            {
              "id": "B",
              "text": "Option A: Decrease the lithium dose by half now to reduce teratogenic risk is inappropriate because empiric halving of the dose risks relapse and does not reflect individualized lithium level monitoring."
            },
            {
              "id": "C",
              "text": "Option B: Stop lithium immediately and observe closely is inappropriate because abrupt discontinuation can precipitate bipolar relapse and is not routinely recommended in a stable patient for whom lithium has been effective."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Switch from lithium to sertraline in the third trimester is inappropriate because sertraline is not a substitute mood stabilizer for bipolar disorder maintenance."
        }
      }
    },
    {
      "externalId": "form7-s4-i008-capacity-understanding",
      "expectedHashes": {
        "ranaze_step3_uat": "7010bbed6abb772988b55a69b0dad84810dea05469b93ae522d567673e6a3740",
        "ranaze_step3_prd": "7010bbed6abb772988b55a69b0dad84810dea05469b93ae522d567673e6a3740"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His family disagrees with him is inappropriate because family disagreement does not determine capacity."
            },
            {
              "id": "B",
              "text": "Option B: He is agitated is inappropriate because agitation can coexist with intact capacity and is not sufficient by itself."
            },
            {
              "id": "C",
              "text": "Option C: He distrusts the surgeon\u0027s motives is inappropriate because distrust or paranoia does not automatically eliminate capacity unless it prevents meaningful understanding and reasoning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His family disagrees with him is inappropriate because family disagreement does not determine capacity."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He is agitated is inappropriate because agitation can coexist with intact capacity and is not sufficient by itself."
            },
            {
              "id": "B",
              "text": "Option A: His family disagrees with him is inappropriate because family disagreement does not determine capacity."
            },
            {
              "id": "C",
              "text": "Option C: He distrusts the surgeon\u0027s motives is inappropriate because distrust or paranoia does not automatically eliminate capacity unless it prevents meaningful understanding and reasoning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He is agitated is inappropriate because agitation can coexist with intact capacity and is not sufficient by itself."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He distrusts the surgeon\u0027s motives is inappropriate because distrust or paranoia does not automatically eliminate capacity unless it prevents meaningful understanding and reasoning."
            },
            {
              "id": "B",
              "text": "Option A: His family disagrees with him is inappropriate because family disagreement does not determine capacity."
            },
            {
              "id": "C",
              "text": "Option B: He is agitated is inappropriate because agitation can coexist with intact capacity and is not sufficient by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He distrusts the surgeon\u0027s motives is inappropriate because distrust or paranoia does not automatically eliminate capacity unless it prevents meaningful understanding and reasoning."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He is hyperventilating is inappropriate because hyperventilation says nothing specific about capacity."
            },
            {
              "id": "B",
              "text": "Option A: His family disagrees with him is inappropriate because family disagreement does not determine capacity."
            },
            {
              "id": "C",
              "text": "Option B: He is agitated is inappropriate because agitation can coexist with intact capacity and is not sufficient by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He is hyperventilating is inappropriate because hyperventilation says nothing specific about capacity."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He smells of alcohol is inappropriate because alcohol odor raises concern but does not by itself establish incapacity."
            },
            {
              "id": "B",
              "text": "Option A: His family disagrees with him is inappropriate because family disagreement does not determine capacity."
            },
            {
              "id": "C",
              "text": "Option B: He is agitated is inappropriate because agitation can coexist with intact capacity and is not sufficient by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He smells of alcohol is inappropriate because alcohol odor raises concern but does not by itself establish incapacity."
        }
      }
    },
    {
      "externalId": "form7-s4-i010-advance-directive-cpr-discussion",
      "expectedHashes": {
        "ranaze_step3_uat": "f04896d78af918a90bef41c42c9a898db2ff9a9fc6e944d9e195c1b919e902e6",
        "ranaze_step3_prd": "f04896d78af918a90bef41c42c9a898db2ff9a9fc6e944d9e195c1b919e902e6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I need a copy of the living will before we discuss anything else.\u0022 is inappropriate because obtaining documents matters, but the best immediate response is to discuss the content and implications of CPR preferences."
            },
            {
              "id": "B",
              "text": "Option B: \u0022You do not need a living will because your cancer is in remission.\u0022 is inappropriate because advance care planning is valuable regardless of current health status."
            },
            {
              "id": "C",
              "text": "Option C: \u0022The nurse will witness your statement and we will enter a do-not-resuscitate order today.\u0022 is inappropriate because a code status order should follow an informed discussion, not be entered reflexively from a single statement in clinic."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I need a copy of the living will before we discuss anything else.\u0022 is inappropriate because obtaining documents matters, but the best immediate response is to discuss the content and implications of CPR preferences."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022You do not need a living will because your cancer is in remission.\u0022 is inappropriate because advance care planning is valuable regardless of current health status."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I need a copy of the living will before we discuss anything else.\u0022 is inappropriate because obtaining documents matters, but the best immediate response is to discuss the content and implications of CPR preferences."
            },
            {
              "id": "C",
              "text": "Option C: \u0022The nurse will witness your statement and we will enter a do-not-resuscitate order today.\u0022 is inappropriate because a code status order should follow an informed discussion, not be entered reflexively from a single statement in clinic."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022You do not need a living will because your cancer is in remission.\u0022 is inappropriate because advance care planning is valuable regardless of current health status."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022The nurse will witness your statement and we will enter a do-not-resuscitate order today.\u0022 is inappropriate because a code status order should follow an informed discussion, not be entered reflexively from a single statement in clinic."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I need a copy of the living will before we discuss anything else.\u0022 is inappropriate because obtaining documents matters, but the best immediate response is to discuss the content and implications of CPR preferences."
            },
            {
              "id": "C",
              "text": "Option B: \u0022You do not need a living will because your cancer is in remission.\u0022 is inappropriate because advance care planning is valuable regardless of current health status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022The nurse will witness your statement and we will enter a do-not-resuscitate order today.\u0022 is inappropriate because a code status order should follow an informed discussion, not be entered reflexively from a single statement in clinic."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Who is your health care power of attorney? That is all I need to know.\u0022 is inappropriate because identifying a surrogate is helpful but incomplete without exploring the patient\u0027s own wishes."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I need a copy of the living will before we discuss anything else.\u0022 is inappropriate because obtaining documents matters, but the best immediate response is to discuss the content and implications of CPR preferences."
            },
            {
              "id": "C",
              "text": "Option B: \u0022You do not need a living will because your cancer is in remission.\u0022 is inappropriate because advance care planning is valuable regardless of current health status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Who is your health care power of attorney? That is all I need to know.\u0022 is inappropriate because identifying a surrogate is helpful but incomplete without exploring the patient\u0027s own wishes."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Advance directives should be postponed until you have a terminal diagnosis.\u0022 is inappropriate because advance care planning is recommended for all adults, not just those with terminal disease."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I need a copy of the living will before we discuss anything else.\u0022 is inappropriate because obtaining documents matters, but the best immediate response is to discuss the content and implications of CPR preferences."
            },
            {
              "id": "C",
              "text": "Option B: \u0022You do not need a living will because your cancer is in remission.\u0022 is inappropriate because advance care planning is valuable regardless of current health status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Advance directives should be postponed until you have a terminal diagnosis.\u0022 is inappropriate because advance care planning is recommended for all adults, not just those with terminal disease."
        }
      }
    },
    {
      "externalId": "form7-s4-i011-pyelonephritis-pregnancy-ceftriaxone",
      "expectedHashes": {
        "ranaze_step3_uat": "79dced686256d29d70fced9dea7c9fd7753deabf4b42899f246cdc0635cd7c9a",
        "ranaze_step3_prd": "79dced686256d29d70fced9dea7c9fd7753deabf4b42899f246cdc0635cd7c9a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ciprofloxacin is inappropriate because fluoroquinolones are generally avoided in pregnancy."
            },
            {
              "id": "B",
              "text": "Option C: Tetracyclines are contraindicated in pregnancy."
            },
            {
              "id": "C",
              "text": "Option D: Trimethoprim-sulfamethoxazole is inappropriate because tMP-SMX is generally avoided in the first trimester when alternatives exist because trimethoprim antagonizes folate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ciprofloxacin is inappropriate because fluoroquinolones are generally avoided in pregnancy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tetracyclines are contraindicated in pregnancy."
            },
            {
              "id": "B",
              "text": "Option B: Ciprofloxacin is inappropriate because fluoroquinolones are generally avoided in pregnancy."
            },
            {
              "id": "C",
              "text": "Option D: Trimethoprim-sulfamethoxazole is inappropriate because tMP-SMX is generally avoided in the first trimester when alternatives exist because trimethoprim antagonizes folate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tetracyclines are contraindicated in pregnancy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Trimethoprim-sulfamethoxazole is inappropriate because tMP-SMX is generally avoided in the first trimester when alternatives exist because trimethoprim antagonizes folate."
            },
            {
              "id": "B",
              "text": "Option B: Ciprofloxacin is inappropriate because fluoroquinolones are generally avoided in pregnancy."
            },
            {
              "id": "C",
              "text": "Option C: Tetracyclines are contraindicated in pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Trimethoprim-sulfamethoxazole is inappropriate because tMP-SMX is generally avoided in the first trimester when alternatives exist because trimethoprim antagonizes folate."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nitrofurantoin is used for lower urinary infections, not pyelonephritis."
            },
            {
              "id": "B",
              "text": "Option B: Ciprofloxacin is inappropriate because fluoroquinolones are generally avoided in pregnancy."
            },
            {
              "id": "C",
              "text": "Option C: Tetracyclines are contraindicated in pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nitrofurantoin is used for lower urinary infections, not pyelonephritis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Doxycycline, like other tetracyclines, is avoided in pregnancy."
            },
            {
              "id": "B",
              "text": "Option B: Ciprofloxacin is inappropriate because fluoroquinolones are generally avoided in pregnancy."
            },
            {
              "id": "C",
              "text": "Option C: Tetracyclines are contraindicated in pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Doxycycline, like other tetracyclines, is avoided in pregnancy."
        }
      }
    },
    {
      "externalId": "form7-s4-i017",
      "expectedHashes": {
        "ranaze_step3_uat": "03233116075539fecf5eeca423f725a6ce337e519bf369d217baa910eb931b1b",
        "ranaze_step3_prd": "03233116075539fecf5eeca423f725a6ce337e519bf369d217baa910eb931b1b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute thrombin overproduction causing diffuse microthrombi is inappropriate because diffuse microthrombi would suggest thrombotic microangiopathy with hemolysis and schistocytes, not an IgM-associated hyperviscosity syndrome with sausage-link retinal veins."
            },
            {
              "id": "B",
              "text": "Option C: Reduced angiotensin degradation causing malignant hypertension is inappropriate because his blood pressure is elevated but not in a malignant range and does not explain the paraprotein-associated retinal finding."
            },
            {
              "id": "C",
              "text": "Option D: Inappropriate antidiuretic hormone release causing cerebral edema is inappropriate because sIADH does not explain the retinal venous changes and elevated IgM."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute thrombin overproduction causing diffuse microthrombi is inappropriate because diffuse microthrombi would suggest thrombotic microangiopathy with hemolysis and schistocytes, not an IgM-associated hyperviscosity syndrome with sausage-link retinal veins."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduced angiotensin degradation causing malignant hypertension is inappropriate because his blood pressure is elevated but not in a malignant range and does not explain the paraprotein-associated retinal finding."
            },
            {
              "id": "B",
              "text": "Option B: Acute thrombin overproduction causing diffuse microthrombi is inappropriate because diffuse microthrombi would suggest thrombotic microangiopathy with hemolysis and schistocytes, not an IgM-associated hyperviscosity syndrome with sausage-link retinal veins."
            },
            {
              "id": "C",
              "text": "Option D: Inappropriate antidiuretic hormone release causing cerebral edema is inappropriate because sIADH does not explain the retinal venous changes and elevated IgM."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduced angiotensin degradation causing malignant hypertension is inappropriate because his blood pressure is elevated but not in a malignant range and does not explain the paraprotein-associated retinal finding."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inappropriate antidiuretic hormone release causing cerebral edema is inappropriate because sIADH does not explain the retinal venous changes and elevated IgM."
            },
            {
              "id": "B",
              "text": "Option B: Acute thrombin overproduction causing diffuse microthrombi is inappropriate because diffuse microthrombi would suggest thrombotic microangiopathy with hemolysis and schistocytes, not an IgM-associated hyperviscosity syndrome with sausage-link retinal veins."
            },
            {
              "id": "C",
              "text": "Option C: Reduced angiotensin degradation causing malignant hypertension is inappropriate because his blood pressure is elevated but not in a malignant range and does not explain the paraprotein-associated retinal finding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inappropriate antidiuretic hormone release causing cerebral edema is inappropriate because sIADH does not explain the retinal venous changes and elevated IgM."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased capillary leak causing retinal hemorrhage is inappropriate because capillary leak does not account for the elevated IgM level and classic hyperviscosity funduscopic findings."
            },
            {
              "id": "B",
              "text": "Option B: Acute thrombin overproduction causing diffuse microthrombi is inappropriate because diffuse microthrombi would suggest thrombotic microangiopathy with hemolysis and schistocytes, not an IgM-associated hyperviscosity syndrome with sausage-link retinal veins."
            },
            {
              "id": "C",
              "text": "Option C: Reduced angiotensin degradation causing malignant hypertension is inappropriate because his blood pressure is elevated but not in a malignant range and does not explain the paraprotein-associated retinal finding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased capillary leak causing retinal hemorrhage is inappropriate because capillary leak does not account for the elevated IgM level and classic hyperviscosity funduscopic findings."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Autoimmune destruction of platelets causing mucosal ischemia is inappropriate because mild thrombocytopenia can cause bleeding, not hyperviscosity with visual blurring and confusion."
            },
            {
              "id": "B",
              "text": "Option B: Acute thrombin overproduction causing diffuse microthrombi is inappropriate because diffuse microthrombi would suggest thrombotic microangiopathy with hemolysis and schistocytes, not an IgM-associated hyperviscosity syndrome with sausage-link retinal veins."
            },
            {
              "id": "C",
              "text": "Option C: Reduced angiotensin degradation causing malignant hypertension is inappropriate because his blood pressure is elevated but not in a malignant range and does not explain the paraprotein-associated retinal finding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Autoimmune destruction of platelets causing mucosal ischemia is inappropriate because mild thrombocytopenia can cause bleeding, not hyperviscosity with visual blurring and confusion."
        }
      }
    },
    {
      "externalId": "form7-s4-i029",
      "expectedHashes": {
        "ranaze_step3_uat": "7a9f9f1d48c10022a7281ba8320c93dec20294bb9761b0a3dd9c5d15fa98954c",
        "ranaze_step3_prd": "7a9f9f1d48c10022a7281ba8320c93dec20294bb9761b0a3dd9c5d15fa98954c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "There is a statistically significant reduction in meningitis with treatment is inappropriate because statistical significance is not established when P = 0.15."
            },
            {
              "id": "B",
              "text": "Option C: There is a statistically significant increase in meningitis with treatment is inappropriate because the event rate numerically trends lower, not higher, in the treated group."
            },
            {
              "id": "C",
              "text": "Option D: The treatment effect is proven absent is inappropriate because the stem shows an observed numerical difference, not proof that the effect is absent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "There is a statistically significant reduction in meningitis with treatment is inappropriate because statistical significance is not established when P = 0.15."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "There is a statistically significant increase in meningitis with treatment is inappropriate because the event rate numerically trends lower, not higher, in the treated group."
            },
            {
              "id": "B",
              "text": "Option B: There is a statistically significant reduction in meningitis with treatment is inappropriate because statistical significance is not established when P = 0.15."
            },
            {
              "id": "C",
              "text": "Option D: The treatment effect is proven absent is inappropriate because the stem shows an observed numerical difference, not proof that the effect is absent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "There is a statistically significant increase in meningitis with treatment is inappropriate because the event rate numerically trends lower, not higher, in the treated group."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The treatment effect is proven absent is inappropriate because the stem shows an observed numerical difference, not proof that the effect is absent."
            },
            {
              "id": "B",
              "text": "Option B: There is a statistically significant reduction in meningitis with treatment is inappropriate because statistical significance is not established when P = 0.15."
            },
            {
              "id": "C",
              "text": "Option C: There is a statistically significant increase in meningitis with treatment is inappropriate because the event rate numerically trends lower, not higher, in the treated group."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The treatment effect is proven absent is inappropriate because the stem shows an observed numerical difference, not proof that the effect is absent."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The treatment is clinically useless because P is above 0.05 is inappropriate because statistical nonsignificance does not by itself determine clinical uselessness."
            },
            {
              "id": "B",
              "text": "Option B: There is a statistically significant reduction in meningitis with treatment is inappropriate because statistical significance is not established when P = 0.15."
            },
            {
              "id": "C",
              "text": "Option C: There is a statistically significant increase in meningitis with treatment is inappropriate because the event rate numerically trends lower, not higher, in the treated group."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The treatment is clinically useless because P is above 0.05 is inappropriate because statistical nonsignificance does not by itself determine clinical uselessness."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The study proves treated infants are more likely to develop meningitis is inappropriate because the observed event counts do not show higher risk with treatment."
            },
            {
              "id": "B",
              "text": "Option B: There is a statistically significant reduction in meningitis with treatment is inappropriate because statistical significance is not established when P = 0.15."
            },
            {
              "id": "C",
              "text": "Option C: There is a statistically significant increase in meningitis with treatment is inappropriate because the event rate numerically trends lower, not higher, in the treated group."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The study proves treated infants are more likely to develop meningitis is inappropriate because the observed event counts do not show higher risk with treatment."
        }
      }
    },
    {
      "externalId": "form7-s4-i030",
      "expectedHashes": {
        "ranaze_step3_uat": "562fe8b19e29b258255bf2adad448dd6b12bf029aabbc86e2fe361a05c9019a8",
        "ranaze_step3_prd": "562fe8b19e29b258255bf2adad448dd6b12bf029aabbc86e2fe361a05c9019a8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The study had a 73% chance of proving the null hypothesis true is inappropriate because power does not describe the probability that the null hypothesis is true."
            },
            {
              "id": "B",
              "text": "Option C: The observed absolute difference is clinically unimportant is inappropriate because power is about detection capability, not clinical importance."
            },
            {
              "id": "C",
              "text": "Option D: The study had a 27% chance of making a type I error is inappropriate because type I error is alpha, not statistical power."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The study had a 73% chance of proving the null hypothesis true is inappropriate because power does not describe the probability that the null hypothesis is true."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The observed absolute difference is clinically unimportant is inappropriate because power is about detection capability, not clinical importance."
            },
            {
              "id": "B",
              "text": "Option B: The study had a 73% chance of proving the null hypothesis true is inappropriate because power does not describe the probability that the null hypothesis is true."
            },
            {
              "id": "C",
              "text": "Option D: The study had a 27% chance of making a type I error is inappropriate because type I error is alpha, not statistical power."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The observed absolute difference is clinically unimportant is inappropriate because power is about detection capability, not clinical importance."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The study had a 27% chance of making a type I error is inappropriate because type I error is alpha, not statistical power."
            },
            {
              "id": "B",
              "text": "Option B: The study had a 73% chance of proving the null hypothesis true is inappropriate because power does not describe the probability that the null hypothesis is true."
            },
            {
              "id": "C",
              "text": "Option C: The observed absolute difference is clinically unimportant is inappropriate because power is about detection capability, not clinical importance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The study had a 27% chance of making a type I error is inappropriate because type I error is alpha, not statistical power."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The treatment effect cannot exist because power was low is inappropriate because low power does not rule out a true effect; it means the study may miss it."
            },
            {
              "id": "B",
              "text": "Option B: The study had a 73% chance of proving the null hypothesis true is inappropriate because power does not describe the probability that the null hypothesis is true."
            },
            {
              "id": "C",
              "text": "Option C: The observed absolute difference is clinically unimportant is inappropriate because power is about detection capability, not clinical importance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The treatment effect cannot exist because power was low is inappropriate because low power does not rule out a true effect; it means the study may miss it."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The results automatically generalize to all populations is inappropriate because power says nothing about external validity."
            },
            {
              "id": "B",
              "text": "Option B: The study had a 73% chance of proving the null hypothesis true is inappropriate because power does not describe the probability that the null hypothesis is true."
            },
            {
              "id": "C",
              "text": "Option C: The observed absolute difference is clinically unimportant is inappropriate because power is about detection capability, not clinical importance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The results automatically generalize to all populations is inappropriate because power says nothing about external validity."
        }
      }
    },
    {
      "externalId": "form7-s4-i031",
      "expectedHashes": {
        "ranaze_step3_uat": "90b189c027dad0951c1be36a4de3da8910b6f0952d0eaff8eaa412d00315a03b",
        "ranaze_step3_prd": "90b189c027dad0951c1be36a4de3da8910b6f0952d0eaff8eaa412d00315a03b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassure her that this is normal and no evaluation is needed is inappropriate because the stem includes a symptom concerning for depression and should not be normalized away without evaluation."
            },
            {
              "id": "B",
              "text": "Option C: Prescribe a benzodiazepine immediately is inappropriate because medication should not precede assessment, and benzodiazepines are not first-line treatment for suspected depression."
            },
            {
              "id": "C",
              "text": "Option D: Order overnight polysomnography is inappropriate because her symptoms are more suggestive of a mood disorder than a primary indication for polysomnography."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassure her that this is normal and no evaluation is needed is inappropriate because the stem includes a symptom concerning for depression and should not be normalized away without evaluation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe a benzodiazepine immediately is inappropriate because medication should not precede assessment, and benzodiazepines are not first-line treatment for suspected depression."
            },
            {
              "id": "B",
              "text": "Option B: Reassure her that this is normal and no evaluation is needed is inappropriate because the stem includes a symptom concerning for depression and should not be normalized away without evaluation."
            },
            {
              "id": "C",
              "text": "Option D: Order overnight polysomnography is inappropriate because her symptoms are more suggestive of a mood disorder than a primary indication for polysomnography."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe a benzodiazepine immediately is inappropriate because medication should not precede assessment, and benzodiazepines are not first-line treatment for suspected depression."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order overnight polysomnography is inappropriate because her symptoms are more suggestive of a mood disorder than a primary indication for polysomnography."
            },
            {
              "id": "B",
              "text": "Option B: Reassure her that this is normal and no evaluation is needed is inappropriate because the stem includes a symptom concerning for depression and should not be normalized away without evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe a benzodiazepine immediately is inappropriate because medication should not precede assessment, and benzodiazepines are not first-line treatment for suspected depression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order overnight polysomnography is inappropriate because her symptoms are more suggestive of a mood disorder than a primary indication for polysomnography."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tell her to return only if suicidal thoughts develop is inappropriate because possible depressive symptoms should be assessed now, not deferred until crisis develops."
            },
            {
              "id": "B",
              "text": "Option B: Reassure her that this is normal and no evaluation is needed is inappropriate because the stem includes a symptom concerning for depression and should not be normalized away without evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe a benzodiazepine immediately is inappropriate because medication should not precede assessment, and benzodiazepines are not first-line treatment for suspected depression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tell her to return only if suicidal thoughts develop is inappropriate because possible depressive symptoms should be assessed now, not deferred until crisis develops."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend an over-the-counter sleep aid without further assessment is inappropriate because symptomatic sleep treatment without evaluation misses a likely mood disorder."
            },
            {
              "id": "B",
              "text": "Option B: Reassure her that this is normal and no evaluation is needed is inappropriate because the stem includes a symptom concerning for depression and should not be normalized away without evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe a benzodiazepine immediately is inappropriate because medication should not precede assessment, and benzodiazepines are not first-line treatment for suspected depression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend an over-the-counter sleep aid without further assessment is inappropriate because symptomatic sleep treatment without evaluation misses a likely mood disorder."
        }
      }
    },
    {
      "externalId": "form7-s4-i033",
      "expectedHashes": {
        "ranaze_step3_uat": "b15080f6d18e7d394507de0d1aaa96af02020a272fc3c822e2227ef6645ea0a2",
        "ranaze_step3_prd": "b15080f6d18e7d394507de0d1aaa96af02020a272fc3c822e2227ef6645ea0a2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The positive predictive value is lower in this infant is inappropriate because positive predictive value falls when prevalence falls, not when prevalence rises as it does in a premature infant."
            },
            {
              "id": "B",
              "text": "Option C: The sensitivity is higher in this infant is inappropriate because sensitivity is a property of the test, not a consequence of this infant\u0027s higher baseline risk."
            },
            {
              "id": "C",
              "text": "Option D: The specificity is higher in this infant is inappropriate because specificity is also a property of the test and does not become higher simply because the infant was premature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The positive predictive value is lower in this infant is inappropriate because positive predictive value falls when prevalence falls, not when prevalence rises as it does in a premature infant."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The sensitivity is higher in this infant is inappropriate because sensitivity is a property of the test, not a consequence of this infant\u0027s higher baseline risk."
            },
            {
              "id": "B",
              "text": "Option B: The positive predictive value is lower in this infant is inappropriate because positive predictive value falls when prevalence falls, not when prevalence rises as it does in a premature infant."
            },
            {
              "id": "C",
              "text": "Option D: The specificity is higher in this infant is inappropriate because specificity is also a property of the test and does not become higher simply because the infant was premature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The sensitivity is higher in this infant is inappropriate because sensitivity is a property of the test, not a consequence of this infant\u0027s higher baseline risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The specificity is higher in this infant is inappropriate because specificity is also a property of the test and does not become higher simply because the infant was premature."
            },
            {
              "id": "B",
              "text": "Option B: The positive predictive value is lower in this infant is inappropriate because positive predictive value falls when prevalence falls, not when prevalence rises as it does in a premature infant."
            },
            {
              "id": "C",
              "text": "Option C: The sensitivity is higher in this infant is inappropriate because sensitivity is a property of the test, not a consequence of this infant\u0027s higher baseline risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The specificity is higher in this infant is inappropriate because specificity is also a property of the test and does not become higher simply because the infant was premature."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The false-positive rate is lower in this infant is inappropriate because false-positive rate is derived from specificity, which the stem does not change."
            },
            {
              "id": "B",
              "text": "Option B: The positive predictive value is lower in this infant is inappropriate because positive predictive value falls when prevalence falls, not when prevalence rises as it does in a premature infant."
            },
            {
              "id": "C",
              "text": "Option C: The sensitivity is higher in this infant is inappropriate because sensitivity is a property of the test, not a consequence of this infant\u0027s higher baseline risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The false-positive rate is lower in this infant is inappropriate because false-positive rate is derived from specificity, which the stem does not change."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The abnormal screen is essentially diagnostic of permanent hearing loss is inappropriate because a failed screen still requires confirmatory diagnostic testing, which is why auditory brainstem response testing is already scheduled."
            },
            {
              "id": "B",
              "text": "Option B: The positive predictive value is lower in this infant is inappropriate because positive predictive value falls when prevalence falls, not when prevalence rises as it does in a premature infant."
            },
            {
              "id": "C",
              "text": "Option C: The sensitivity is higher in this infant is inappropriate because sensitivity is a property of the test, not a consequence of this infant\u0027s higher baseline risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The abnormal screen is essentially diagnostic of permanent hearing loss is inappropriate because a failed screen still requires confirmatory diagnostic testing, which is why auditory brainstem response testing is already scheduled."
        }
      }
    },
    {
      "externalId": "form7-s4-i034",
      "expectedHashes": {
        "ranaze_step3_uat": "77d433c8213e3301eb93b7b8028bcc7d782dae9abbc4e8405cb457e4c58e38cd",
        "ranaze_step3_prd": "77d433c8213e3301eb93b7b8028bcc7d782dae9abbc4e8405cb457e4c58e38cd"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin clonazepam at bedtime is inappropriate because benzodiazepines are not first-line treatment for a child with post-traumatic anxiety symptoms and can worsen functioning and avoidance."
            },
            {
              "id": "B",
              "text": "Option C: Begin fluoxetine is inappropriate because an SSRI is not the best initial step for this short-duration, trauma-linked presentation when psychotherapy is available."
            },
            {
              "id": "C",
              "text": "Option D: Arrange repeated unsupervised exposure to neighborhood dogs is inappropriate because exposure work, when used, should be structured and therapist-guided rather than unsupervised self-exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin clonazepam at bedtime is inappropriate because benzodiazepines are not first-line treatment for a child with post-traumatic anxiety symptoms and can worsen functioning and avoidance."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin fluoxetine is inappropriate because an SSRI is not the best initial step for this short-duration, trauma-linked presentation when psychotherapy is available."
            },
            {
              "id": "B",
              "text": "Option A: Begin clonazepam at bedtime is inappropriate because benzodiazepines are not first-line treatment for a child with post-traumatic anxiety symptoms and can worsen functioning and avoidance."
            },
            {
              "id": "C",
              "text": "Option D: Arrange repeated unsupervised exposure to neighborhood dogs is inappropriate because exposure work, when used, should be structured and therapist-guided rather than unsupervised self-exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin fluoxetine is inappropriate because an SSRI is not the best initial step for this short-duration, trauma-linked presentation when psychotherapy is available."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange repeated unsupervised exposure to neighborhood dogs is inappropriate because exposure work, when used, should be structured and therapist-guided rather than unsupervised self-exposure."
            },
            {
              "id": "B",
              "text": "Option A: Begin clonazepam at bedtime is inappropriate because benzodiazepines are not first-line treatment for a child with post-traumatic anxiety symptoms and can worsen functioning and avoidance."
            },
            {
              "id": "C",
              "text": "Option C: Begin fluoxetine is inappropriate because an SSRI is not the best initial step for this short-duration, trauma-linked presentation when psychotherapy is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange repeated unsupervised exposure to neighborhood dogs is inappropriate because exposure work, when used, should be structured and therapist-guided rather than unsupervised self-exposure."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide reassurance only and no follow-up is inappropriate because reassurance alone is insufficient because the stem describes ongoing nightmares, avoidance, and insomnia beyond a brief transient fright response."
            },
            {
              "id": "B",
              "text": "Option A: Begin clonazepam at bedtime is inappropriate because benzodiazepines are not first-line treatment for a child with post-traumatic anxiety symptoms and can worsen functioning and avoidance."
            },
            {
              "id": "C",
              "text": "Option C: Begin fluoxetine is inappropriate because an SSRI is not the best initial step for this short-duration, trauma-linked presentation when psychotherapy is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide reassurance only and no follow-up is inappropriate because reassurance alone is insufficient because the stem describes ongoing nightmares, avoidance, and insomnia beyond a brief transient fright response."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend immediate hospitalization is inappropriate because there is no evidence of suicidality, psychosis, medical instability, or inability to function safely at home."
            },
            {
              "id": "B",
              "text": "Option A: Begin clonazepam at bedtime is inappropriate because benzodiazepines are not first-line treatment for a child with post-traumatic anxiety symptoms and can worsen functioning and avoidance."
            },
            {
              "id": "C",
              "text": "Option C: Begin fluoxetine is inappropriate because an SSRI is not the best initial step for this short-duration, trauma-linked presentation when psychotherapy is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend immediate hospitalization is inappropriate because there is no evidence of suicidality, psychosis, medical instability, or inability to function safely at home."
        }
      }
    },
    {
      "externalId": "form7-s4-i035",
      "expectedHashes": {
        "ranaze_step3_uat": "f6455d492b0ea3938260a7a906eb57383b2dfe2e5802c8e30c65ef9efd66c00e",
        "ranaze_step3_prd": "f6455d492b0ea3938260a7a906eb57383b2dfe2e5802c8e30c65ef9efd66c00e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prior basal cell carcinomas is inappropriate because basal cell carcinoma reflects ultraviolet skin damage, not the strongest risk link for vulvar squamous carcinoma in this stem."
            },
            {
              "id": "B",
              "text": "Option C: Topical corticosteroid use for psoriasis is inappropriate because limited topical corticosteroid use is not the classic risk factor being tested here."
            },
            {
              "id": "C",
              "text": "Option D: Psoriasis itself is not the key risk factor for vulvar squamous carcinoma in this vignette."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prior basal cell carcinomas is inappropriate because basal cell carcinoma reflects ultraviolet skin damage, not the strongest risk link for vulvar squamous carcinoma in this stem."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical corticosteroid use for psoriasis is inappropriate because limited topical corticosteroid use is not the classic risk factor being tested here."
            },
            {
              "id": "B",
              "text": "Option A: Prior basal cell carcinomas is inappropriate because basal cell carcinoma reflects ultraviolet skin damage, not the strongest risk link for vulvar squamous carcinoma in this stem."
            },
            {
              "id": "C",
              "text": "Option D: Psoriasis itself is not the key risk factor for vulvar squamous carcinoma in this vignette."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical corticosteroid use for psoriasis is inappropriate because limited topical corticosteroid use is not the classic risk factor being tested here."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Psoriasis itself is not the key risk factor for vulvar squamous carcinoma in this vignette."
            },
            {
              "id": "B",
              "text": "Option A: Prior basal cell carcinomas is inappropriate because basal cell carcinoma reflects ultraviolet skin damage, not the strongest risk link for vulvar squamous carcinoma in this stem."
            },
            {
              "id": "C",
              "text": "Option C: Topical corticosteroid use for psoriasis is inappropriate because limited topical corticosteroid use is not the classic risk factor being tested here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Psoriasis itself is not the key risk factor for vulvar squamous carcinoma in this vignette."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remote tanning bed exposure is inappropriate because tanning beds increase ultraviolet-related skin cancers, but that history does not explain vulvar squamous carcinoma as directly as prior HPV-related dysplasia."
            },
            {
              "id": "B",
              "text": "Option A: Prior basal cell carcinomas is inappropriate because basal cell carcinoma reflects ultraviolet skin damage, not the strongest risk link for vulvar squamous carcinoma in this stem."
            },
            {
              "id": "C",
              "text": "Option C: Topical corticosteroid use for psoriasis is inappropriate because limited topical corticosteroid use is not the classic risk factor being tested here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remote tanning bed exposure is inappropriate because tanning beds increase ultraviolet-related skin cancers, but that history does not explain vulvar squamous carcinoma as directly as prior HPV-related dysplasia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Essential hypertension is inappropriate because hypertension has no causal relationship to vulvar squamous carcinoma."
            },
            {
              "id": "B",
              "text": "Option A: Prior basal cell carcinomas is inappropriate because basal cell carcinoma reflects ultraviolet skin damage, not the strongest risk link for vulvar squamous carcinoma in this stem."
            },
            {
              "id": "C",
              "text": "Option C: Topical corticosteroid use for psoriasis is inappropriate because limited topical corticosteroid use is not the classic risk factor being tested here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Essential hypertension is inappropriate because hypertension has no causal relationship to vulvar squamous carcinoma."
        }
      }
    },
    {
      "externalId": "form7-s4-i036",
      "expectedHashes": {
        "ranaze_step3_uat": "95c2cf9dd8c22dd5b7343213822929c5847a947ef9f4c413eceae18e3f6a92ed",
        "ranaze_step3_prd": "95c2cf9dd8c22dd5b7343213822929c5847a947ef9f4c413eceae18e3f6a92ed"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transient diabetes caused entirely by a brief corticosteroid course is inappropriate because a brief steroid course can worsen glucose, but the funduscopic evidence shows chronic diabetes predating the recent treatment."
            },
            {
              "id": "B",
              "text": "Option C: Exocrine pancreatic insufficiency would not explain the retinal findings of long-standing diabetes."
            },
            {
              "id": "C",
              "text": "Option D: New autoimmune type 1 diabetes triggered by the recent viral illness is inappropriate because new autoimmune type 1 diabetes is less likely because she has no ketonuria and has retinal findings of chronic disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transient diabetes caused entirely by a brief corticosteroid course is inappropriate because a brief steroid course can worsen glucose, but the funduscopic evidence shows chronic diabetes predating the recent treatment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exocrine pancreatic insufficiency would not explain the retinal findings of long-standing diabetes."
            },
            {
              "id": "B",
              "text": "Option A: Transient diabetes caused entirely by a brief corticosteroid course is inappropriate because a brief steroid course can worsen glucose, but the funduscopic evidence shows chronic diabetes predating the recent treatment."
            },
            {
              "id": "C",
              "text": "Option D: New autoimmune type 1 diabetes triggered by the recent viral illness is inappropriate because new autoimmune type 1 diabetes is less likely because she has no ketonuria and has retinal findings of chronic disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exocrine pancreatic insufficiency would not explain the retinal findings of long-standing diabetes."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "New autoimmune type 1 diabetes triggered by the recent viral illness is inappropriate because new autoimmune type 1 diabetes is less likely because she has no ketonuria and has retinal findings of chronic disease."
            },
            {
              "id": "B",
              "text": "Option A: Transient diabetes caused entirely by a brief corticosteroid course is inappropriate because a brief steroid course can worsen glucose, but the funduscopic evidence shows chronic diabetes predating the recent treatment."
            },
            {
              "id": "C",
              "text": "Option C: Exocrine pancreatic insufficiency would not explain the retinal findings of long-standing diabetes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "New autoimmune type 1 diabetes triggered by the recent viral illness is inappropriate because new autoimmune type 1 diabetes is less likely because she has no ketonuria and has retinal findings of chronic disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Polyglandular autoimmune syndrome is inappropriate because there is no stem evidence of multiple autoimmune endocrinopathies."
            },
            {
              "id": "B",
              "text": "Option A: Transient diabetes caused entirely by a brief corticosteroid course is inappropriate because a brief steroid course can worsen glucose, but the funduscopic evidence shows chronic diabetes predating the recent treatment."
            },
            {
              "id": "C",
              "text": "Option C: Exocrine pancreatic insufficiency would not explain the retinal findings of long-standing diabetes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Polyglandular autoimmune syndrome is inappropriate because there is no stem evidence of multiple autoimmune endocrinopathies."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Factitious hyperglycemia from albuterol use is inappropriate because albuterol does not explain marked persistent hyperglycemia with diabetic retinopathy."
            },
            {
              "id": "B",
              "text": "Option A: Transient diabetes caused entirely by a brief corticosteroid course is inappropriate because a brief steroid course can worsen glucose, but the funduscopic evidence shows chronic diabetes predating the recent treatment."
            },
            {
              "id": "C",
              "text": "Option C: Exocrine pancreatic insufficiency would not explain the retinal findings of long-standing diabetes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Factitious hyperglycemia from albuterol use is inappropriate because albuterol does not explain marked persistent hyperglycemia with diabetic retinopathy."
        }
      }
    },
    {
      "externalId": "form7-s4-i037",
      "expectedHashes": {
        "ranaze_step3_uat": "6fb468210eff2a0260f38884b37e5b8a455352bdfb210ddfd87e418f985cfbe9",
        "ranaze_step3_prd": "6fb468210eff2a0260f38884b37e5b8a455352bdfb210ddfd87e418f985cfbe9"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start broad-spectrum antibiotics is inappropriate because aspiration or pneumonia is not the first priority in a profoundly hypothermic drowning victim."
            },
            {
              "id": "B",
              "text": "Option B: Give high-dose corticosteroids is inappropriate because corticosteroids do not treat the primary problem of accidental hypothermia."
            },
            {
              "id": "C",
              "text": "Option C: Begin inotropic support before other measures is inappropriate because circulatory support may be needed later, but initial management centers on rewarming the severely hypothermic patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start broad-spectrum antibiotics is inappropriate because aspiration or pneumonia is not the first priority in a profoundly hypothermic drowning victim."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give high-dose corticosteroids is inappropriate because corticosteroids do not treat the primary problem of accidental hypothermia."
            },
            {
              "id": "B",
              "text": "Option A: Start broad-spectrum antibiotics is inappropriate because aspiration or pneumonia is not the first priority in a profoundly hypothermic drowning victim."
            },
            {
              "id": "C",
              "text": "Option C: Begin inotropic support before other measures is inappropriate because circulatory support may be needed later, but initial management centers on rewarming the severely hypothermic patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give high-dose corticosteroids is inappropriate because corticosteroids do not treat the primary problem of accidental hypothermia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin inotropic support before other measures is inappropriate because circulatory support may be needed later, but initial management centers on rewarming the severely hypothermic patient."
            },
            {
              "id": "B",
              "text": "Option A: Start broad-spectrum antibiotics is inappropriate because aspiration or pneumonia is not the first priority in a profoundly hypothermic drowning victim."
            },
            {
              "id": "C",
              "text": "Option B: Give high-dose corticosteroids is inappropriate because corticosteroids do not treat the primary problem of accidental hypothermia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin inotropic support before other measures is inappropriate because circulatory support may be needed later, but initial management centers on rewarming the severely hypothermic patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Deeply sedate the patient is inappropriate because he is already intubated; sedation does not address the life-threatening hypothermia."
            },
            {
              "id": "B",
              "text": "Option A: Start broad-spectrum antibiotics is inappropriate because aspiration or pneumonia is not the first priority in a profoundly hypothermic drowning victim."
            },
            {
              "id": "C",
              "text": "Option B: Give high-dose corticosteroids is inappropriate because corticosteroids do not treat the primary problem of accidental hypothermia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Deeply sedate the patient is inappropriate because he is already intubated; sedation does not address the life-threatening hypothermia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give loop diuretics immediately is inappropriate because pulmonary edema after drowning does not supersede the need to correct profound hypothermia first."
            },
            {
              "id": "B",
              "text": "Option A: Start broad-spectrum antibiotics is inappropriate because aspiration or pneumonia is not the first priority in a profoundly hypothermic drowning victim."
            },
            {
              "id": "C",
              "text": "Option B: Give high-dose corticosteroids is inappropriate because corticosteroids do not treat the primary problem of accidental hypothermia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give loop diuretics immediately is inappropriate because pulmonary edema after drowning does not supersede the need to correct profound hypothermia first."
        }
      }
    },
    {
      "externalId": "form7-s4-i038",
      "expectedHashes": {
        "ranaze_step3_uat": "7729757119c6ffa2441310d137ed5072231012f0380ca8ac28d002b57dd2b345",
        "ranaze_step3_prd": "7729757119c6ffa2441310d137ed5072231012f0380ca8ac28d002b57dd2b345"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Advise her to stop running competitively is inappropriate because the stem does not show low BMI, disordered eating, or other evidence that exercise suppression is currently indicated."
            },
            {
              "id": "B",
              "text": "Option B: Start combined oral contraceptive therapy is inappropriate because empiric oral contraceptives would treat the calendar rather than address whether evaluation is even yet indicated."
            },
            {
              "id": "C",
              "text": "Option C: Recommend a high-calorie diet for presumed energy deficiency is inappropriate because she has a normal BMI and denies restrictive eating, so the stem does not support presumed energy deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Advise her to stop running competitively is inappropriate because the stem does not show low BMI, disordered eating, or other evidence that exercise suppression is currently indicated."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start combined oral contraceptive therapy is inappropriate because empiric oral contraceptives would treat the calendar rather than address whether evaluation is even yet indicated."
            },
            {
              "id": "B",
              "text": "Option A: Advise her to stop running competitively is inappropriate because the stem does not show low BMI, disordered eating, or other evidence that exercise suppression is currently indicated."
            },
            {
              "id": "C",
              "text": "Option C: Recommend a high-calorie diet for presumed energy deficiency is inappropriate because she has a normal BMI and denies restrictive eating, so the stem does not support presumed energy deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start combined oral contraceptive therapy is inappropriate because empiric oral contraceptives would treat the calendar rather than address whether evaluation is even yet indicated."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend a high-calorie diet for presumed energy deficiency is inappropriate because she has a normal BMI and denies restrictive eating, so the stem does not support presumed energy deficiency."
            },
            {
              "id": "B",
              "text": "Option A: Advise her to stop running competitively is inappropriate because the stem does not show low BMI, disordered eating, or other evidence that exercise suppression is currently indicated."
            },
            {
              "id": "C",
              "text": "Option B: Start combined oral contraceptive therapy is inappropriate because empiric oral contraceptives would treat the calendar rather than address whether evaluation is even yet indicated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend a high-calorie diet for presumed energy deficiency is inappropriate because she has a normal BMI and denies restrictive eating, so the stem does not support presumed energy deficiency."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer now for endocrine evaluation of primary amenorrhea is inappropriate because she has not yet reached the usual threshold for evaluation because she is 14 and only 2 years from thelarche."
            },
            {
              "id": "B",
              "text": "Option A: Advise her to stop running competitively is inappropriate because the stem does not show low BMI, disordered eating, or other evidence that exercise suppression is currently indicated."
            },
            {
              "id": "C",
              "text": "Option B: Start combined oral contraceptive therapy is inappropriate because empiric oral contraceptives would treat the calendar rather than address whether evaluation is even yet indicated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer now for endocrine evaluation of primary amenorrhea is inappropriate because she has not yet reached the usual threshold for evaluation because she is 14 and only 2 years from thelarche."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order pituitary MRI immediately is inappropriate because there are no neurologic symptoms, galactorrhea, or other findings suggesting a pituitary mass."
            },
            {
              "id": "B",
              "text": "Option A: Advise her to stop running competitively is inappropriate because the stem does not show low BMI, disordered eating, or other evidence that exercise suppression is currently indicated."
            },
            {
              "id": "C",
              "text": "Option B: Start combined oral contraceptive therapy is inappropriate because empiric oral contraceptives would treat the calendar rather than address whether evaluation is even yet indicated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order pituitary MRI immediately is inappropriate because there are no neurologic symptoms, galactorrhea, or other findings suggesting a pituitary mass."
        }
      }
    },
    {
      "externalId": "form7-s4-i039",
      "expectedHashes": {
        "ranaze_step3_uat": "b3f2f05cd1f997b67c04b0f5cf6c58dfa41260529166ccf9fe0e969b12c687a7",
        "ranaze_step3_prd": "b3f2f05cd1f997b67c04b0f5cf6c58dfa41260529166ccf9fe0e969b12c687a7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dystrophic calcification of the pleura is inappropriate because pleural plaques indicate prior asbestos exposure but do not explain the diffuse restrictive interstitial disease as directly as fibrosis does."
            },
            {
              "id": "B",
              "text": "Option B: Granulomatous inflammation suggests diseases such as sarcoidosis or certain pneumoconioses, not classic asbestosis with ferruginous bodies."
            },
            {
              "id": "C",
              "text": "Option C: IgE-mediated hypersensitivity does not fit the occupational history, pleural plaques, and ferruginous bodies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dystrophic calcification of the pleura is inappropriate because pleural plaques indicate prior asbestos exposure but do not explain the diffuse restrictive interstitial disease as directly as fibrosis does."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Granulomatous inflammation suggests diseases such as sarcoidosis or certain pneumoconioses, not classic asbestosis with ferruginous bodies."
            },
            {
              "id": "B",
              "text": "Option A: Dystrophic calcification of the pleura is inappropriate because pleural plaques indicate prior asbestos exposure but do not explain the diffuse restrictive interstitial disease as directly as fibrosis does."
            },
            {
              "id": "C",
              "text": "Option C: IgE-mediated hypersensitivity does not fit the occupational history, pleural plaques, and ferruginous bodies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Granulomatous inflammation suggests diseases such as sarcoidosis or certain pneumoconioses, not classic asbestosis with ferruginous bodies."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IgE-mediated hypersensitivity does not fit the occupational history, pleural plaques, and ferruginous bodies."
            },
            {
              "id": "B",
              "text": "Option A: Dystrophic calcification of the pleura is inappropriate because pleural plaques indicate prior asbestos exposure but do not explain the diffuse restrictive interstitial disease as directly as fibrosis does."
            },
            {
              "id": "C",
              "text": "Option B: Granulomatous inflammation suggests diseases such as sarcoidosis or certain pneumoconioses, not classic asbestosis with ferruginous bodies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IgE-mediated hypersensitivity does not fit the occupational history, pleural plaques, and ferruginous bodies."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Large-airway bronchospasm is inappropriate because bronchospasm would cause an obstructive rather than restrictive pattern."
            },
            {
              "id": "B",
              "text": "Option A: Dystrophic calcification of the pleura is inappropriate because pleural plaques indicate prior asbestos exposure but do not explain the diffuse restrictive interstitial disease as directly as fibrosis does."
            },
            {
              "id": "C",
              "text": "Option B: Granulomatous inflammation suggests diseases such as sarcoidosis or certain pneumoconioses, not classic asbestosis with ferruginous bodies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Large-airway bronchospasm is inappropriate because bronchospasm would cause an obstructive rather than restrictive pattern."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary vascular embolization is inappropriate because pulmonary embolization would not explain pleural plaques and ferruginous bodies."
            },
            {
              "id": "B",
              "text": "Option A: Dystrophic calcification of the pleura is inappropriate because pleural plaques indicate prior asbestos exposure but do not explain the diffuse restrictive interstitial disease as directly as fibrosis does."
            },
            {
              "id": "C",
              "text": "Option B: Granulomatous inflammation suggests diseases such as sarcoidosis or certain pneumoconioses, not classic asbestosis with ferruginous bodies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary vascular embolization is inappropriate because pulmonary embolization would not explain pleural plaques and ferruginous bodies."
        }
      }
    },
    {
      "externalId": "form7-s4-i040",
      "expectedHashes": {
        "ranaze_step3_uat": "4c1484a59bd3d8c5bc032ec69c680af7c5077de2b6fa01e82184d41d4b46bb78",
        "ranaze_step3_prd": "4c1484a59bd3d8c5bc032ec69c680af7c5077de2b6fa01e82184d41d4b46bb78"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mean and standard deviation are most appropriate for roughly symmetric distributions without strong outliers."
            },
            {
              "id": "B",
              "text": "Option B: Mean and standard error is inappropriate because standard error describes the precision of an estimated mean, not the variability among individual patients."
            },
            {
              "id": "C",
              "text": "Option D: Median and standard deviation is inappropriate because standard deviation is still heavily influenced by skew and outliers even if the median is used for center."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mean and standard deviation are most appropriate for roughly symmetric distributions without strong outliers."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mean and standard error is inappropriate because standard error describes the precision of an estimated mean, not the variability among individual patients."
            },
            {
              "id": "B",
              "text": "Option A: Mean and standard deviation are most appropriate for roughly symmetric distributions without strong outliers."
            },
            {
              "id": "C",
              "text": "Option D: Median and standard deviation is inappropriate because standard deviation is still heavily influenced by skew and outliers even if the median is used for center."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mean and standard error is inappropriate because standard error describes the precision of an estimated mean, not the variability among individual patients."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Median and standard deviation is inappropriate because standard deviation is still heavily influenced by skew and outliers even if the median is used for center."
            },
            {
              "id": "B",
              "text": "Option A: Mean and standard deviation are most appropriate for roughly symmetric distributions without strong outliers."
            },
            {
              "id": "C",
              "text": "Option B: Mean and standard error is inappropriate because standard error describes the precision of an estimated mean, not the variability among individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Median and standard deviation is inappropriate because standard deviation is still heavily influenced by skew and outliers even if the median is used for center."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mode and interquartile range is inappropriate because the mode is not the preferred summary of central tendency for continuous skewed clinical data."
            },
            {
              "id": "B",
              "text": "Option A: Mean and standard deviation are most appropriate for roughly symmetric distributions without strong outliers."
            },
            {
              "id": "C",
              "text": "Option B: Mean and standard error is inappropriate because standard error describes the precision of an estimated mean, not the variability among individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mode and interquartile range is inappropriate because the mode is not the preferred summary of central tendency for continuous skewed clinical data."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mode and standard deviation is inappropriate because this combines a nonpreferred measure of center with a spread measure sensitive to skew."
            },
            {
              "id": "B",
              "text": "Option A: Mean and standard deviation are most appropriate for roughly symmetric distributions without strong outliers."
            },
            {
              "id": "C",
              "text": "Option B: Mean and standard error is inappropriate because standard error describes the precision of an estimated mean, not the variability among individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mode and standard deviation is inappropriate because this combines a nonpreferred measure of center with a spread measure sensitive to skew."
        }
      }
    },
    {
      "externalId": "form7-s4-i042",
      "expectedHashes": {
        "ranaze_step3_uat": "297920d78cd79019cd55f2f1b2aedb5d04d334c3c64561e2a5cc7109c4d8bf2e",
        "ranaze_step3_prd": "297920d78cd79019cd55f2f1b2aedb5d04d334c3c64561e2a5cc7109c4d8bf2e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop warfarin 1 day before surgery and give fresh frozen plasma immediately before surgery is inappropriate because holding warfarin only 1 day is inadequate for planned reversal, and fresh frozen plasma is unnecessary for routine elective management."
            },
            {
              "id": "B",
              "text": "Option B: Stop warfarin 1 day before surgery and replace it with aspirin after surgery is inappropriate because aspirin is not an appropriate substitute for anticoagulation in atrial fibrillation and 1 day is too short a hold."
            },
            {
              "id": "C",
              "text": "Option D: Stop warfarin 5 days before surgery and bridge with therapeutic heparin until surgery is inappropriate because bridging is reserved for selected very high-risk patients, which this stem does not describe."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop warfarin 1 day before surgery and give fresh frozen plasma immediately before surgery is inappropriate because holding warfarin only 1 day is inadequate for planned reversal, and fresh frozen plasma is unnecessary for routine elective management."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop warfarin 1 day before surgery and replace it with aspirin after surgery is inappropriate because aspirin is not an appropriate substitute for anticoagulation in atrial fibrillation and 1 day is too short a hold."
            },
            {
              "id": "B",
              "text": "Option A: Stop warfarin 1 day before surgery and give fresh frozen plasma immediately before surgery is inappropriate because holding warfarin only 1 day is inadequate for planned reversal, and fresh frozen plasma is unnecessary for routine elective management."
            },
            {
              "id": "C",
              "text": "Option D: Stop warfarin 5 days before surgery and bridge with therapeutic heparin until surgery is inappropriate because bridging is reserved for selected very high-risk patients, which this stem does not describe."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop warfarin 1 day before surgery and replace it with aspirin after surgery is inappropriate because aspirin is not an appropriate substitute for anticoagulation in atrial fibrillation and 1 day is too short a hold."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop warfarin 5 days before surgery and bridge with therapeutic heparin until surgery is inappropriate because bridging is reserved for selected very high-risk patients, which this stem does not describe."
            },
            {
              "id": "B",
              "text": "Option A: Stop warfarin 1 day before surgery and give fresh frozen plasma immediately before surgery is inappropriate because holding warfarin only 1 day is inadequate for planned reversal, and fresh frozen plasma is unnecessary for routine elective management."
            },
            {
              "id": "C",
              "text": "Option B: Stop warfarin 1 day before surgery and replace it with aspirin after surgery is inappropriate because aspirin is not an appropriate substitute for anticoagulation in atrial fibrillation and 1 day is too short a hold."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop warfarin 5 days before surgery and bridge with therapeutic heparin until surgery is inappropriate because bridging is reserved for selected very high-risk patients, which this stem does not describe."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue warfarin through surgery is inappropriate because warfarin is usually interrupted before elective abdominal surgery because of bleeding risk."
            },
            {
              "id": "B",
              "text": "Option A: Stop warfarin 1 day before surgery and give fresh frozen plasma immediately before surgery is inappropriate because holding warfarin only 1 day is inadequate for planned reversal, and fresh frozen plasma is unnecessary for routine elective management."
            },
            {
              "id": "C",
              "text": "Option B: Stop warfarin 1 day before surgery and replace it with aspirin after surgery is inappropriate because aspirin is not an appropriate substitute for anticoagulation in atrial fibrillation and 1 day is too short a hold."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue warfarin through surgery is inappropriate because warfarin is usually interrupted before elective abdominal surgery because of bleeding risk."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop warfarin on the morning of surgery only is inappropriate because same-day interruption is inadequate because warfarin\u0027s anticoagulant effect persists for days."
            },
            {
              "id": "B",
              "text": "Option A: Stop warfarin 1 day before surgery and give fresh frozen plasma immediately before surgery is inappropriate because holding warfarin only 1 day is inadequate for planned reversal, and fresh frozen plasma is unnecessary for routine elective management."
            },
            {
              "id": "C",
              "text": "Option B: Stop warfarin 1 day before surgery and replace it with aspirin after surgery is inappropriate because aspirin is not an appropriate substitute for anticoagulation in atrial fibrillation and 1 day is too short a hold."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop warfarin on the morning of surgery only is inappropriate because same-day interruption is inadequate because warfarin\u0027s anticoagulant effect persists for days."
        }
      }
    },
    {
      "externalId": "form7-s4-i045",
      "expectedHashes": {
        "ranaze_step3_uat": "719340a19fd08ad41ce5119d189116b3334a0144351759a13bae98b7ff194894",
        "ranaze_step3_prd": "719340a19fd08ad41ce5119d189116b3334a0144351759a13bae98b7ff194894"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I find it confusing and probably incorrect.\u0022 is inappropriate because directly arguing about the belief is unnecessarily confrontational and may damage rapport."
            },
            {
              "id": "B",
              "text": "Option B: \u0022Tell me more about it.\u0022 is inappropriate because this is more open-ended, but it risks inviting elaboration of delusional content without first using an empathic, nonendorsing reflection."
            },
            {
              "id": "C",
              "text": "Option C: \u0022It seems improbable, but I understand your logic.\u0022 is inappropriate because saying you understand the logic partially validates the belief content."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I find it confusing and probably incorrect.\u0022 is inappropriate because directly arguing about the belief is unnecessarily confrontational and may damage rapport."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Tell me more about it.\u0022 is inappropriate because this is more open-ended, but it risks inviting elaboration of delusional content without first using an empathic, nonendorsing reflection."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I find it confusing and probably incorrect.\u0022 is inappropriate because directly arguing about the belief is unnecessarily confrontational and may damage rapport."
            },
            {
              "id": "C",
              "text": "Option C: \u0022It seems improbable, but I understand your logic.\u0022 is inappropriate because saying you understand the logic partially validates the belief content."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Tell me more about it.\u0022 is inappropriate because this is more open-ended, but it risks inviting elaboration of delusional content without first using an empathic, nonendorsing reflection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022It seems improbable, but I understand your logic.\u0022 is inappropriate because saying you understand the logic partially validates the belief content."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I find it confusing and probably incorrect.\u0022 is inappropriate because directly arguing about the belief is unnecessarily confrontational and may damage rapport."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Tell me more about it.\u0022 is inappropriate because this is more open-ended, but it risks inviting elaboration of delusional content without first using an empathic, nonendorsing reflection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022It seems improbable, but I understand your logic.\u0022 is inappropriate because saying you understand the logic partially validates the belief content."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Your ideas are fascinating and likely true.\u0022 is inappropriate because endorsing the belief reinforces psychotic content."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I find it confusing and probably incorrect.\u0022 is inappropriate because directly arguing about the belief is unnecessarily confrontational and may damage rapport."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Tell me more about it.\u0022 is inappropriate because this is more open-ended, but it risks inviting elaboration of delusional content without first using an empathic, nonendorsing reflection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Your ideas are fascinating and likely true.\u0022 is inappropriate because endorsing the belief reinforces psychotic content."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022We should stop discussing this and increase your medication today.\u0022 is inappropriate because the stem does not show agitation, danger, or a need to shut down discussion immediately."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I find it confusing and probably incorrect.\u0022 is inappropriate because directly arguing about the belief is unnecessarily confrontational and may damage rapport."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Tell me more about it.\u0022 is inappropriate because this is more open-ended, but it risks inviting elaboration of delusional content without first using an empathic, nonendorsing reflection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022We should stop discussing this and increase your medication today.\u0022 is inappropriate because the stem does not show agitation, danger, or a need to shut down discussion immediately."
        }
      }
    },
    {
      "externalId": "form7-s4-i047",
      "expectedHashes": {
        "ranaze_step3_uat": "b05862efa8ab7eb2f8190b6b6e716dee3d6d1d6f3dd03078e051c7e01e71a573",
        "ranaze_step3_prd": "b05862efa8ab7eb2f8190b6b6e716dee3d6d1d6f3dd03078e051c7e01e71a573"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Brain MRI is inappropriate because the stem points to an endocrine disorder rather than a primary structural brain lesion."
            },
            {
              "id": "B",
              "text": "Option B: Quantitative plasma amino acid analysis is inappropriate because amino acid disorders do not explain this classic cluster of hypothyroid findings."
            },
            {
              "id": "C",
              "text": "Option C: Serum tissue transglutaminase IgA testing is inappropriate because celiac disease would not explain a hoarse cry, large fontanel, and umbilical hernia in this infant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Brain MRI is inappropriate because the stem points to an endocrine disorder rather than a primary structural brain lesion."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Quantitative plasma amino acid analysis is inappropriate because amino acid disorders do not explain this classic cluster of hypothyroid findings."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI is inappropriate because the stem points to an endocrine disorder rather than a primary structural brain lesion."
            },
            {
              "id": "C",
              "text": "Option C: Serum tissue transglutaminase IgA testing is inappropriate because celiac disease would not explain a hoarse cry, large fontanel, and umbilical hernia in this infant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Quantitative plasma amino acid analysis is inappropriate because amino acid disorders do not explain this classic cluster of hypothyroid findings."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum tissue transglutaminase IgA testing is inappropriate because celiac disease would not explain a hoarse cry, large fontanel, and umbilical hernia in this infant."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI is inappropriate because the stem points to an endocrine disorder rather than a primary structural brain lesion."
            },
            {
              "id": "C",
              "text": "Option B: Quantitative plasma amino acid analysis is inappropriate because amino acid disorders do not explain this classic cluster of hypothyroid findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum tissue transglutaminase IgA testing is inappropriate because celiac disease would not explain a hoarse cry, large fontanel, and umbilical hernia in this infant."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urine culture for cytomegalovirus is inappropriate because congenital CMV may cause developmental issues, but the specific exam findings here are classic for hypothyroidism."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI is inappropriate because the stem points to an endocrine disorder rather than a primary structural brain lesion."
            },
            {
              "id": "C",
              "text": "Option B: Quantitative plasma amino acid analysis is inappropriate because amino acid disorders do not explain this classic cluster of hypothyroid findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urine culture for cytomegalovirus is inappropriate because congenital CMV may cause developmental issues, but the specific exam findings here are classic for hypothyroidism."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sweat chloride testing is inappropriate because cystic fibrosis does not explain the hoarse cry, constipation, large fontanel, and hypotonia pattern."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI is inappropriate because the stem points to an endocrine disorder rather than a primary structural brain lesion."
            },
            {
              "id": "C",
              "text": "Option B: Quantitative plasma amino acid analysis is inappropriate because amino acid disorders do not explain this classic cluster of hypothyroid findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sweat chloride testing is inappropriate because cystic fibrosis does not explain the hoarse cry, constipation, large fontanel, and hypotonia pattern."
        }
      }
    },
    {
      "externalId": "form7-s4-i048",
      "expectedHashes": {
        "ranaze_step3_uat": "2d757c9464162c9666ba02c58b0c1817189dfc5e2682d83b0a24f994e5f50ee5",
        "ranaze_step3_prd": "2d757c9464162c9666ba02c58b0c1817189dfc5e2682d83b0a24f994e5f50ee5"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Drug X should be started because the trial proved a reduction in cardiovascular death is inappropriate because even apart from outcome details, this patient does not match the enrolled population."
            },
            {
              "id": "B",
              "text": "Option B: Drug X should be started because the trial proved prevention of recurrent myocardial infarction in this setting is inappropriate because the question is about applicability to this patient, and he does not satisfy the trial\u0027s inclusion criteria."
            },
            {
              "id": "C",
              "text": "Option D: Drug X should not be started because the trial showed no reduction in heart-failure readmission is inappropriate because the stem does not justify this statement, and the more fundamental issue is nonapplicability to this patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Drug X should be started because the trial proved a reduction in cardiovascular death is inappropriate because even apart from outcome details, this patient does not match the enrolled population."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Drug X should be started because the trial proved prevention of recurrent myocardial infarction in this setting is inappropriate because the question is about applicability to this patient, and he does not satisfy the trial\u0027s inclusion criteria."
            },
            {
              "id": "B",
              "text": "Option A: Drug X should be started because the trial proved a reduction in cardiovascular death is inappropriate because even apart from outcome details, this patient does not match the enrolled population."
            },
            {
              "id": "C",
              "text": "Option D: Drug X should not be started because the trial showed no reduction in heart-failure readmission is inappropriate because the stem does not justify this statement, and the more fundamental issue is nonapplicability to this patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Drug X should be started because the trial proved prevention of recurrent myocardial infarction in this setting is inappropriate because the question is about applicability to this patient, and he does not satisfy the trial\u0027s inclusion criteria."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Drug X should not be started because the trial showed no reduction in heart-failure readmission is inappropriate because the stem does not justify this statement, and the more fundamental issue is nonapplicability to this patient."
            },
            {
              "id": "B",
              "text": "Option A: Drug X should be started because the trial proved a reduction in cardiovascular death is inappropriate because even apart from outcome details, this patient does not match the enrolled population."
            },
            {
              "id": "C",
              "text": "Option B: Drug X should be started because the trial proved prevention of recurrent myocardial infarction in this setting is inappropriate because the question is about applicability to this patient, and he does not satisfy the trial\u0027s inclusion criteria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Drug X should not be started because the trial showed no reduction in heart-failure readmission is inappropriate because the stem does not justify this statement, and the more fundamental issue is nonapplicability to this patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Drug X should not be started because the trial proved harm in chronic systolic heart failure is inappropriate because the stem does not describe proven harm; the main issue is that the patient was not represented in the trial population."
            },
            {
              "id": "B",
              "text": "Option A: Drug X should be started because the trial proved a reduction in cardiovascular death is inappropriate because even apart from outcome details, this patient does not match the enrolled population."
            },
            {
              "id": "C",
              "text": "Option B: Drug X should be started because the trial proved prevention of recurrent myocardial infarction in this setting is inappropriate because the question is about applicability to this patient, and he does not satisfy the trial\u0027s inclusion criteria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Drug X should not be started because the trial proved harm in chronic systolic heart failure is inappropriate because the stem does not describe proven harm; the main issue is that the patient was not represented in the trial population."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Drug X should be started because any ejection fraction below 35% guarantees applicability is inappropriate because a low ejection fraction alone does not override the trial\u0027s requirement for chronic symptomatic heart failure on prior standard therapy."
            },
            {
              "id": "B",
              "text": "Option A: Drug X should be started because the trial proved a reduction in cardiovascular death is inappropriate because even apart from outcome details, this patient does not match the enrolled population."
            },
            {
              "id": "C",
              "text": "Option B: Drug X should be started because the trial proved prevention of recurrent myocardial infarction in this setting is inappropriate because the question is about applicability to this patient, and he does not satisfy the trial\u0027s inclusion criteria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Drug X should be started because any ejection fraction below 35% guarantees applicability is inappropriate because a low ejection fraction alone does not override the trial\u0027s requirement for chronic symptomatic heart failure on prior standard therapy."
        }
      }
    },
    {
      "externalId": "form7-s4-i049",
      "expectedHashes": {
        "ranaze_step3_uat": "ed80995c7efee21dd34596ea4efdf382c86f566a6b24f79c2f197eb1e62465e0",
        "ranaze_step3_prd": "ed80995c7efee21dd34596ea4efdf382c86f566a6b24f79c2f197eb1e62465e0"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start cholestyramine therapy now is inappropriate because drug therapy is not started before confirming the lipid abnormality and severity."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a baseline electrocardiogram is inappropriate because an ECG does not screen for familial hypercholesterolemia."
            },
            {
              "id": "C",
              "text": "Option D: Recommend a structured exercise program as the only intervention is inappropriate because exercise counseling is useful generally, but this child first needs lipid screening given the family history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start cholestyramine therapy now is inappropriate because drug therapy is not started before confirming the lipid abnormality and severity."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a baseline electrocardiogram is inappropriate because an ECG does not screen for familial hypercholesterolemia."
            },
            {
              "id": "B",
              "text": "Option A: Start cholestyramine therapy now is inappropriate because drug therapy is not started before confirming the lipid abnormality and severity."
            },
            {
              "id": "C",
              "text": "Option D: Recommend a structured exercise program as the only intervention is inappropriate because exercise counseling is useful generally, but this child first needs lipid screening given the family history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a baseline electrocardiogram is inappropriate because an ECG does not screen for familial hypercholesterolemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend a structured exercise program as the only intervention is inappropriate because exercise counseling is useful generally, but this child first needs lipid screening given the family history."
            },
            {
              "id": "B",
              "text": "Option A: Start cholestyramine therapy now is inappropriate because drug therapy is not started before confirming the lipid abnormality and severity."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a baseline electrocardiogram is inappropriate because an ECG does not screen for familial hypercholesterolemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend a structured exercise program as the only intervention is inappropriate because exercise counseling is useful generally, but this child first needs lipid screening given the family history."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend a low-fat diet as the only intervention is inappropriate because dietary counseling alone does not replace appropriate diagnostic screening."
            },
            {
              "id": "B",
              "text": "Option A: Start cholestyramine therapy now is inappropriate because drug therapy is not started before confirming the lipid abnormality and severity."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a baseline electrocardiogram is inappropriate because an ECG does not screen for familial hypercholesterolemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend a low-fat diet as the only intervention is inappropriate because dietary counseling alone does not replace appropriate diagnostic screening."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassure the family that no evaluation is needed until adulthood is inappropriate because the family history indicates a need for childhood screening, not deferral until adulthood."
            },
            {
              "id": "B",
              "text": "Option A: Start cholestyramine therapy now is inappropriate because drug therapy is not started before confirming the lipid abnormality and severity."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a baseline electrocardiogram is inappropriate because an ECG does not screen for familial hypercholesterolemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassure the family that no evaluation is needed until adulthood is inappropriate because the family history indicates a need for childhood screening, not deferral until adulthood."
        }
      }
    },
    {
      "externalId": "form7-s4-i050",
      "expectedHashes": {
        "ranaze_step3_uat": "742255c649e98d030aa24fb6c2b470958ad76a8bf9fa98b2a0220faf4a4fb7cb",
        "ranaze_step3_prd": "742255c649e98d030aa24fb6c2b470958ad76a8bf9fa98b2a0220faf4a4fb7cb"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I can be there when you tell your mother.\u0022 is inappropriate because support with disclosure may become appropriate later, but the first step is to explore the patient\u0027s immediate fear and safety concerns."
            },
            {
              "id": "B",
              "text": "Option B: \u0022How much do you already know about herpes, and what questions do you have?\u0022 is inappropriate because education about herpes matters, but it is not the best initial response when the patient is expressing acute fear about a parent reaction."
            },
            {
              "id": "C",
              "text": "Option D: \u0022Your reaction worries me, so tell me about your relationship with your mother.\u0022 is inappropriate because this is more leading and less patient-centered than first asking what specifically worries her most."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I can be there when you tell your mother.\u0022 is inappropriate because support with disclosure may become appropriate later, but the first step is to explore the patient\u0027s immediate fear and safety concerns."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022How much do you already know about herpes, and what questions do you have?\u0022 is inappropriate because education about herpes matters, but it is not the best initial response when the patient is expressing acute fear about a parent reaction."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I can be there when you tell your mother.\u0022 is inappropriate because support with disclosure may become appropriate later, but the first step is to explore the patient\u0027s immediate fear and safety concerns."
            },
            {
              "id": "C",
              "text": "Option D: \u0022Your reaction worries me, so tell me about your relationship with your mother.\u0022 is inappropriate because this is more leading and less patient-centered than first asking what specifically worries her most."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022How much do you already know about herpes, and what questions do you have?\u0022 is inappropriate because education about herpes matters, but it is not the best initial response when the patient is expressing acute fear about a parent reaction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Your reaction worries me, so tell me about your relationship with your mother.\u0022 is inappropriate because this is more leading and less patient-centered than first asking what specifically worries her most."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I can be there when you tell your mother.\u0022 is inappropriate because support with disclosure may become appropriate later, but the first step is to explore the patient\u0027s immediate fear and safety concerns."
            },
            {
              "id": "C",
              "text": "Option B: \u0022How much do you already know about herpes, and what questions do you have?\u0022 is inappropriate because education about herpes matters, but it is not the best initial response when the patient is expressing acute fear about a parent reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Your reaction worries me, so tell me about your relationship with your mother.\u0022 is inappropriate because this is more leading and less patient-centered than first asking what specifically worries her most."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I will keep this completely secret from your mother no matter what.\u0022 is inappropriate because the physician should not promise absolute secrecy regardless of circumstances because safety issues may alter confidentiality duties."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I can be there when you tell your mother.\u0022 is inappropriate because support with disclosure may become appropriate later, but the first step is to explore the patient\u0027s immediate fear and safety concerns."
            },
            {
              "id": "C",
              "text": "Option B: \u0022How much do you already know about herpes, and what questions do you have?\u0022 is inappropriate because education about herpes matters, but it is not the best initial response when the patient is expressing acute fear about a parent reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I will keep this completely secret from your mother no matter what.\u0022 is inappropriate because the physician should not promise absolute secrecy regardless of circumstances because safety issues may alter confidentiality duties."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022You need to tell your mother today before we discuss anything else.\u0022 is inappropriate because immediate directives about disclosure ignore the need to assess safety and the adolescent\u0027s concerns first."
            },
            {
              "id": "B",
              "text": "Option A: \u0022I can be there when you tell your mother.\u0022 is inappropriate because support with disclosure may become appropriate later, but the first step is to explore the patient\u0027s immediate fear and safety concerns."
            },
            {
              "id": "C",
              "text": "Option B: \u0022How much do you already know about herpes, and what questions do you have?\u0022 is inappropriate because education about herpes matters, but it is not the best initial response when the patient is expressing acute fear about a parent reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022You need to tell your mother today before we discuss anything else.\u0022 is inappropriate because immediate directives about disclosure ignore the need to assess safety and the adolescent\u0027s concerns first."
        }
      }
    },
    {
      "externalId": "free137-2019-i057-meningismus-red-flag",
      "expectedHashes": {
        "ranaze_step3_uat": "f56b15f9d32f6a151beba5af65822b1f877d0fcaa472475b5438ee1e8a0e8381",
        "ranaze_step3_prd": "f56b15f9d32f6a151beba5af65822b1f877d0fcaa472475b5438ee1e8a0e8381"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serous middle-ear effusion is inappropriate because a serous effusion may reflect local ear pathology but is not the key urgent clue in this patient with fever, leukocytosis, and meningismus."
            },
            {
              "id": "B",
              "text": "Option B: Expiratory wheezes suggest airway disease but do not explain the urgent headache concern as specifically as meningismus does."
            },
            {
              "id": "C",
              "text": "Option C: A midsystolic click may reflect mitral valve prolapse, but it is not the reason this new headache requires emergent workup."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serous middle-ear effusion is inappropriate because a serous effusion may reflect local ear pathology but is not the key urgent clue in this patient with fever, leukocytosis, and meningismus."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Expiratory wheezes suggest airway disease but do not explain the urgent headache concern as specifically as meningismus does."
            },
            {
              "id": "B",
              "text": "Option A: Serous middle-ear effusion is inappropriate because a serous effusion may reflect local ear pathology but is not the key urgent clue in this patient with fever, leukocytosis, and meningismus."
            },
            {
              "id": "C",
              "text": "Option C: A midsystolic click may reflect mitral valve prolapse, but it is not the reason this new headache requires emergent workup."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Expiratory wheezes suggest airway disease but do not explain the urgent headache concern as specifically as meningismus does."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A midsystolic click may reflect mitral valve prolapse, but it is not the reason this new headache requires emergent workup."
            },
            {
              "id": "B",
              "text": "Option A: Serous middle-ear effusion is inappropriate because a serous effusion may reflect local ear pathology but is not the key urgent clue in this patient with fever, leukocytosis, and meningismus."
            },
            {
              "id": "C",
              "text": "Option B: Expiratory wheezes suggest airway disease but do not explain the urgent headache concern as specifically as meningismus does."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A midsystolic click may reflect mitral valve prolapse, but it is not the reason this new headache requires emergent workup."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Trace bilateral ankle varicosities is inappropriate because varicosities are common and incidental here; they do not account for the immediate neurologic concern."
            },
            {
              "id": "B",
              "text": "Option A: Serous middle-ear effusion is inappropriate because a serous effusion may reflect local ear pathology but is not the key urgent clue in this patient with fever, leukocytosis, and meningismus."
            },
            {
              "id": "C",
              "text": "Option B: Expiratory wheezes suggest airway disease but do not explain the urgent headache concern as specifically as meningismus does."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Trace bilateral ankle varicosities is inappropriate because varicosities are common and incidental here; they do not account for the immediate neurologic concern."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elevated blood pressure is inappropriate because severe hypertension can accompany pain, but the more specific red-flag physical finding for immediate secondary headache evaluation in this stem is meningismus."
            },
            {
              "id": "B",
              "text": "Option A: Serous middle-ear effusion is inappropriate because a serous effusion may reflect local ear pathology but is not the key urgent clue in this patient with fever, leukocytosis, and meningismus."
            },
            {
              "id": "C",
              "text": "Option B: Expiratory wheezes suggest airway disease but do not explain the urgent headache concern as specifically as meningismus does."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elevated blood pressure is inappropriate because severe hypertension can accompany pain, but the more specific red-flag physical finding for immediate secondary headache evaluation in this stem is meningismus."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Photophobia can occur with migraine and meningitis, but neck stiffness is the more specific physical red flag demanding urgent evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Serous middle-ear effusion is inappropriate because a serous effusion may reflect local ear pathology but is not the key urgent clue in this patient with fever, leukocytosis, and meningismus."
            },
            {
              "id": "C",
              "text": "Option B: Expiratory wheezes suggest airway disease but do not explain the urgent headache concern as specifically as meningismus does."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Photophobia can occur with migraine and meningitis, but neck stiffness is the more specific physical red flag demanding urgent evaluation."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A normal funduscopic examination does not remove concern when other red flags for dangerous secondary headache are present."
            },
            {
              "id": "B",
              "text": "Option A: Serous middle-ear effusion is inappropriate because a serous effusion may reflect local ear pathology but is not the key urgent clue in this patient with fever, leukocytosis, and meningismus."
            },
            {
              "id": "C",
              "text": "Option B: Expiratory wheezes suggest airway disease but do not explain the urgent headache concern as specifically as meningismus does."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A normal funduscopic examination does not remove concern when other red flags for dangerous secondary headache are present."
        }
      }
    },
    {
      "externalId": "free137-2019-i092-psychotic-depression-combination-therapy",
      "expectedHashes": {
        "ranaze_step3_uat": "5744647e0d380622a211e3059b10a42cb6df41a892e7856382851e3107dc03b3",
        "ranaze_step3_prd": "5744647e0d380622a211e3059b10a42cb6df41a892e7856382851e3107dc03b3"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Divalproex sodium is inappropriate because divalproex is more appropriate for bipolar disorder or acute mania, which is not suggested by this vignette."
            },
            {
              "id": "B",
              "text": "Option C: Lamotrigine is used for bipolar depression maintenance, not as first-line treatment for unipolar major depression with psychotic features."
            },
            {
              "id": "C",
              "text": "Option D: Lithium carbonate is inappropriate because lithium may be used in bipolar disorder or as augmentation in selected depression cases, but it is not the best next medication here compared with adding an antidepressant for psychotic depression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Divalproex sodium is inappropriate because divalproex is more appropriate for bipolar disorder or acute mania, which is not suggested by this vignette."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lamotrigine is used for bipolar depression maintenance, not as first-line treatment for unipolar major depression with psychotic features."
            },
            {
              "id": "B",
              "text": "Option A: Divalproex sodium is inappropriate because divalproex is more appropriate for bipolar disorder or acute mania, which is not suggested by this vignette."
            },
            {
              "id": "C",
              "text": "Option D: Lithium carbonate is inappropriate because lithium may be used in bipolar disorder or as augmentation in selected depression cases, but it is not the best next medication here compared with adding an antidepressant for psychotic depression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lamotrigine is used for bipolar depression maintenance, not as first-line treatment for unipolar major depression with psychotic features."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lithium carbonate is inappropriate because lithium may be used in bipolar disorder or as augmentation in selected depression cases, but it is not the best next medication here compared with adding an antidepressant for psychotic depression."
            },
            {
              "id": "B",
              "text": "Option A: Divalproex sodium is inappropriate because divalproex is more appropriate for bipolar disorder or acute mania, which is not suggested by this vignette."
            },
            {
              "id": "C",
              "text": "Option C: Lamotrigine is used for bipolar depression maintenance, not as first-line treatment for unipolar major depression with psychotic features."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lithium carbonate is inappropriate because lithium may be used in bipolar disorder or as augmentation in selected depression cases, but it is not the best next medication here compared with adding an antidepressant for psychotic depression."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Buspirone treats anxiety but does not address severe major depression with psychotic symptoms."
            },
            {
              "id": "B",
              "text": "Option A: Divalproex sodium is inappropriate because divalproex is more appropriate for bipolar disorder or acute mania, which is not suggested by this vignette."
            },
            {
              "id": "C",
              "text": "Option C: Lamotrigine is used for bipolar depression maintenance, not as first-line treatment for unipolar major depression with psychotic features."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Buspirone treats anxiety but does not address severe major depression with psychotic symptoms."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No additional medication is needed is inappropriate because antipsychotic monotherapy is generally less appropriate than combined antidepressant-antipsychotic treatment for psychotic depression."
            },
            {
              "id": "B",
              "text": "Option A: Divalproex sodium is inappropriate because divalproex is more appropriate for bipolar disorder or acute mania, which is not suggested by this vignette."
            },
            {
              "id": "C",
              "text": "Option C: Lamotrigine is used for bipolar depression maintenance, not as first-line treatment for unipolar major depression with psychotic features."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No additional medication is needed is inappropriate because antipsychotic monotherapy is generally less appropriate than combined antidepressant-antipsychotic treatment for psychotic depression."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Modafinil may promote wakefulness but does not treat the depressive and psychotic syndrome described."
            },
            {
              "id": "B",
              "text": "Option A: Divalproex sodium is inappropriate because divalproex is more appropriate for bipolar disorder or acute mania, which is not suggested by this vignette."
            },
            {
              "id": "C",
              "text": "Option C: Lamotrigine is used for bipolar depression maintenance, not as first-line treatment for unipolar major depression with psychotic features."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Modafinil may promote wakefulness but does not treat the depressive and psychotic syndrome described."
        }
      }
    },
    {
      "externalId": "free137-2019-i093-plaque-psoriasis-topical-steroid",
      "expectedHashes": {
        "ranaze_step3_uat": "a436184f85dc3eac8962e7154f80fbf758cf7d665d491b3efc29b900d752c907",
        "ranaze_step3_prd": "a436184f85dc3eac8962e7154f80fbf758cf7d665d491b3efc29b900d752c907"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral methotrexate is inappropriate because methotrexate is generally reserved for more extensive, refractory, or arthritis-associated psoriasis rather than limited untreated plaque disease."
            },
            {
              "id": "B",
              "text": "Option B: Narrowband UVB phototherapy is inappropriate because phototherapy is effective but is not the best initial treatment for limited psoriasis that is amenable to topical therapy."
            },
            {
              "id": "C",
              "text": "Option C: Oral cyclosporine is inappropriate because cyclosporine is a systemic option for severe or difficult-to-control psoriasis, not stable limited plaques at first presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral methotrexate is inappropriate because methotrexate is generally reserved for more extensive, refractory, or arthritis-associated psoriasis rather than limited untreated plaque disease."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Narrowband UVB phototherapy is inappropriate because phototherapy is effective but is not the best initial treatment for limited psoriasis that is amenable to topical therapy."
            },
            {
              "id": "B",
              "text": "Option A: Oral methotrexate is inappropriate because methotrexate is generally reserved for more extensive, refractory, or arthritis-associated psoriasis rather than limited untreated plaque disease."
            },
            {
              "id": "C",
              "text": "Option C: Oral cyclosporine is inappropriate because cyclosporine is a systemic option for severe or difficult-to-control psoriasis, not stable limited plaques at first presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Narrowband UVB phototherapy is inappropriate because phototherapy is effective but is not the best initial treatment for limited psoriasis that is amenable to topical therapy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral cyclosporine is inappropriate because cyclosporine is a systemic option for severe or difficult-to-control psoriasis, not stable limited plaques at first presentation."
            },
            {
              "id": "B",
              "text": "Option A: Oral methotrexate is inappropriate because methotrexate is generally reserved for more extensive, refractory, or arthritis-associated psoriasis rather than limited untreated plaque disease."
            },
            {
              "id": "C",
              "text": "Option B: Narrowband UVB phototherapy is inappropriate because phototherapy is effective but is not the best initial treatment for limited psoriasis that is amenable to topical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral cyclosporine is inappropriate because cyclosporine is a systemic option for severe or difficult-to-control psoriasis, not stable limited plaques at first presentation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral cholecalciferol supplementation is inappropriate because oral vitamin D supplementation is not a standard treatment for plaque psoriasis."
            },
            {
              "id": "B",
              "text": "Option A: Oral methotrexate is inappropriate because methotrexate is generally reserved for more extensive, refractory, or arthritis-associated psoriasis rather than limited untreated plaque disease."
            },
            {
              "id": "C",
              "text": "Option B: Narrowband UVB phototherapy is inappropriate because phototherapy is effective but is not the best initial treatment for limited psoriasis that is amenable to topical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral cholecalciferol supplementation is inappropriate because oral vitamin D supplementation is not a standard treatment for plaque psoriasis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Adalimumab is inappropriate because biologic therapy is usually reserved for moderate to severe disease, refractory cases, or significant psoriatic arthritis."
            },
            {
              "id": "B",
              "text": "Option A: Oral methotrexate is inappropriate because methotrexate is generally reserved for more extensive, refractory, or arthritis-associated psoriasis rather than limited untreated plaque disease."
            },
            {
              "id": "C",
              "text": "Option B: Narrowband UVB phototherapy is inappropriate because phototherapy is effective but is not the best initial treatment for limited psoriasis that is amenable to topical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Adalimumab is inappropriate because biologic therapy is usually reserved for moderate to severe disease, refractory cases, or significant psoriatic arthritis."
        }
      }
    },
    {
      "externalId": "free137-2019-i115-coarctation-hypertension",
      "expectedHashes": {
        "ranaze_step3_uat": "8b40dade87eb68329658154e0c45636bfb45619f774f2f83b34da857a1c9a3a6",
        "ranaze_step3_prd": "8b40dade87eb68329658154e0c45636bfb45619f774f2f83b34da857a1c9a3a6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Progressive right-sided heart failure from pulmonary vascular disease is inappropriate because pulmonary vascular disease with cor pulmonale is more characteristic of longstanding left-to-right shunt lesions, not isolated coarctation."
            },
            {
              "id": "B",
              "text": "Option B: Chronic atrial fibrillation due to left atrial enlargement is inappropriate because atrial fibrillation is usually driven by atrial enlargement or major valvular disease; this vignette points to left ventricular pressure overload instead."
            },
            {
              "id": "C",
              "text": "Option C: Severe tricuspid regurgitation from right ventricular dilation is inappropriate because tricuspid regurgitation from right ventricular dilation is not a typical consequence of isolated coarctation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Progressive right-sided heart failure from pulmonary vascular disease is inappropriate because pulmonary vascular disease with cor pulmonale is more characteristic of longstanding left-to-right shunt lesions, not isolated coarctation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic atrial fibrillation due to left atrial enlargement is inappropriate because atrial fibrillation is usually driven by atrial enlargement or major valvular disease; this vignette points to left ventricular pressure overload instead."
            },
            {
              "id": "B",
              "text": "Option A: Progressive right-sided heart failure from pulmonary vascular disease is inappropriate because pulmonary vascular disease with cor pulmonale is more characteristic of longstanding left-to-right shunt lesions, not isolated coarctation."
            },
            {
              "id": "C",
              "text": "Option C: Severe tricuspid regurgitation from right ventricular dilation is inappropriate because tricuspid regurgitation from right ventricular dilation is not a typical consequence of isolated coarctation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic atrial fibrillation due to left atrial enlargement is inappropriate because atrial fibrillation is usually driven by atrial enlargement or major valvular disease; this vignette points to left ventricular pressure overload instead."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Severe tricuspid regurgitation from right ventricular dilation is inappropriate because tricuspid regurgitation from right ventricular dilation is not a typical consequence of isolated coarctation."
            },
            {
              "id": "B",
              "text": "Option A: Progressive right-sided heart failure from pulmonary vascular disease is inappropriate because pulmonary vascular disease with cor pulmonale is more characteristic of longstanding left-to-right shunt lesions, not isolated coarctation."
            },
            {
              "id": "C",
              "text": "Option B: Chronic atrial fibrillation due to left atrial enlargement is inappropriate because atrial fibrillation is usually driven by atrial enlargement or major valvular disease; this vignette points to left ventricular pressure overload instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Severe tricuspid regurgitation from right ventricular dilation is inappropriate because tricuspid regurgitation from right ventricular dilation is not a typical consequence of isolated coarctation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Infective endocarditis as the most likely long-term event is inappropriate because endocarditis can occur in some congenital lesions, but it is not the most likely long-term complication here."
            },
            {
              "id": "B",
              "text": "Option A: Progressive right-sided heart failure from pulmonary vascular disease is inappropriate because pulmonary vascular disease with cor pulmonale is more characteristic of longstanding left-to-right shunt lesions, not isolated coarctation."
            },
            {
              "id": "C",
              "text": "Option B: Chronic atrial fibrillation due to left atrial enlargement is inappropriate because atrial fibrillation is usually driven by atrial enlargement or major valvular disease; this vignette points to left ventricular pressure overload instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Infective endocarditis as the most likely long-term event is inappropriate because endocarditis can occur in some congenital lesions, but it is not the most likely long-term complication here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cyanosis from reversal of an intracardiac shunt is inappropriate because cyanosis from shunt reversal requires a significant intracardiac or great-vessel shunt with pulmonary vascular remodeling, which is not described here."
            },
            {
              "id": "B",
              "text": "Option A: Progressive right-sided heart failure from pulmonary vascular disease is inappropriate because pulmonary vascular disease with cor pulmonale is more characteristic of longstanding left-to-right shunt lesions, not isolated coarctation."
            },
            {
              "id": "C",
              "text": "Option B: Chronic atrial fibrillation due to left atrial enlargement is inappropriate because atrial fibrillation is usually driven by atrial enlargement or major valvular disease; this vignette points to left ventricular pressure overload instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cyanosis from reversal of an intracardiac shunt is inappropriate because cyanosis from shunt reversal requires a significant intracardiac or great-vessel shunt with pulmonary vascular remodeling, which is not described here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Complete atrioventricular block is inappropriate because complete heart block is not a typical natural-history complication of coarctation of the aorta."
            },
            {
              "id": "B",
              "text": "Option A: Progressive right-sided heart failure from pulmonary vascular disease is inappropriate because pulmonary vascular disease with cor pulmonale is more characteristic of longstanding left-to-right shunt lesions, not isolated coarctation."
            },
            {
              "id": "C",
              "text": "Option B: Chronic atrial fibrillation due to left atrial enlargement is inappropriate because atrial fibrillation is usually driven by atrial enlargement or major valvular disease; this vignette points to left ventricular pressure overload instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Complete atrioventricular block is inappropriate because complete heart block is not a typical natural-history complication of coarctation of the aorta."
        }
      }
    },
    {
      "externalId": "free137-2019-i122-hemophilia-xlinked-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "44eacb67fefa9a08ea45bbdb463178ddfd19369cb33aa88560965e3c5f4033b3",
        "ranaze_step3_prd": "44eacb67fefa9a08ea45bbdb463178ddfd19369cb33aa88560965e3c5f4033b3"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Because this fetus will receive a Y chromosome from his father, he is not at risk for hemophilia A is inappropriate because the fetus\u0027s father does provide the Y chromosome, but the fetus\u0027s only X chromosome comes from the mother, whose family history makes her a carrier-risk woman."
            },
            {
              "id": "B",
              "text": "Option B: This fetus has a 25% chance of hemophilia A is inappropriate because a 25% estimate applies before fetal sex is known for all pregnancies combined; once the fetus is known to be male, the relevant risk is 50%."
            },
            {
              "id": "C",
              "text": "Option D: This fetus has a 50% chance of being an asymptomatic carrier of hemophilia A is inappropriate because a male fetus with one X chromosome is typically either affected or unaffected, not an asymptomatic carrier."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Because this fetus will receive a Y chromosome from his father, he is not at risk for hemophilia A is inappropriate because the fetus\u0027s father does provide the Y chromosome, but the fetus\u0027s only X chromosome comes from the mother, whose family history makes her a carrier-risk woman."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This fetus has a 25% chance of hemophilia A is inappropriate because a 25% estimate applies before fetal sex is known for all pregnancies combined; once the fetus is known to be male, the relevant risk is 50%."
            },
            {
              "id": "B",
              "text": "Option A: Because this fetus will receive a Y chromosome from his father, he is not at risk for hemophilia A is inappropriate because the fetus\u0027s father does provide the Y chromosome, but the fetus\u0027s only X chromosome comes from the mother, whose family history makes her a carrier-risk woman."
            },
            {
              "id": "C",
              "text": "Option D: This fetus has a 50% chance of being an asymptomatic carrier of hemophilia A is inappropriate because a male fetus with one X chromosome is typically either affected or unaffected, not an asymptomatic carrier."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This fetus has a 25% chance of hemophilia A is inappropriate because a 25% estimate applies before fetal sex is known for all pregnancies combined; once the fetus is known to be male, the relevant risk is 50%."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This fetus has a 50% chance of being an asymptomatic carrier of hemophilia A is inappropriate because a male fetus with one X chromosome is typically either affected or unaffected, not an asymptomatic carrier."
            },
            {
              "id": "B",
              "text": "Option A: Because this fetus will receive a Y chromosome from his father, he is not at risk for hemophilia A is inappropriate because the fetus\u0027s father does provide the Y chromosome, but the fetus\u0027s only X chromosome comes from the mother, whose family history makes her a carrier-risk woman."
            },
            {
              "id": "C",
              "text": "Option B: This fetus has a 25% chance of hemophilia A is inappropriate because a 25% estimate applies before fetal sex is known for all pregnancies combined; once the fetus is known to be male, the relevant risk is 50%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This fetus has a 50% chance of being an asymptomatic carrier of hemophilia A is inappropriate because a male fetus with one X chromosome is typically either affected or unaffected, not an asymptomatic carrier."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This fetus has a 100% chance of hemophilia A is inappropriate because the patient transmits only one of her two X chromosomes to each son, so the fetus is not certain to inherit the pathogenic variant."
            },
            {
              "id": "B",
              "text": "Option A: Because this fetus will receive a Y chromosome from his father, he is not at risk for hemophilia A is inappropriate because the fetus\u0027s father does provide the Y chromosome, but the fetus\u0027s only X chromosome comes from the mother, whose family history makes her a carrier-risk woman."
            },
            {
              "id": "C",
              "text": "Option B: This fetus has a 25% chance of hemophilia A is inappropriate because a 25% estimate applies before fetal sex is known for all pregnancies combined; once the fetus is known to be male, the relevant risk is 50%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This fetus has a 100% chance of hemophilia A is inappropriate because the patient transmits only one of her two X chromosomes to each son, so the fetus is not certain to inherit the pathogenic variant."
        }
      }
    },
    {
      "externalId": "free137-2019-i133-airway-protection-variceal-bleed",
      "expectedHashes": {
        "ranaze_step3_uat": "d86fa1f5eeb068f4853a6aebd8610a24e8ca22c723d50b606455dba0b79b624a",
        "ranaze_step3_prd": "d86fa1f5eeb068f4853a6aebd8610a24e8ca22c723d50b606455dba0b79b624a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start intravenous octreotide infusion is inappropriate because octreotide is appropriate early therapy for suspected variceal bleeding, but it does not address the patient\u0027s immediate airway threat from active hematemesis and somnolence."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous ceftriaxone prophylaxis is inappropriate because antibiotic prophylaxis is recommended in acute variceal hemorrhage, but airway protection takes priority when the patient is losing consciousness and aspirating blood."
            },
            {
              "id": "C",
              "text": "Option C: Proceed directly to urgent upper endoscopy is inappropriate because urgent endoscopy is needed after stabilization, but this patient should not be taken directly for endoscopy before the airway is secured."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start intravenous octreotide infusion is inappropriate because octreotide is appropriate early therapy for suspected variceal bleeding, but it does not address the patient\u0027s immediate airway threat from active hematemesis and somnolence."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous ceftriaxone prophylaxis is inappropriate because antibiotic prophylaxis is recommended in acute variceal hemorrhage, but airway protection takes priority when the patient is losing consciousness and aspirating blood."
            },
            {
              "id": "B",
              "text": "Option A: Start intravenous octreotide infusion is inappropriate because octreotide is appropriate early therapy for suspected variceal bleeding, but it does not address the patient\u0027s immediate airway threat from active hematemesis and somnolence."
            },
            {
              "id": "C",
              "text": "Option C: Proceed directly to urgent upper endoscopy is inappropriate because urgent endoscopy is needed after stabilization, but this patient should not be taken directly for endoscopy before the airway is secured."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous ceftriaxone prophylaxis is inappropriate because antibiotic prophylaxis is recommended in acute variceal hemorrhage, but airway protection takes priority when the patient is losing consciousness and aspirating blood."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly to urgent upper endoscopy is inappropriate because urgent endoscopy is needed after stabilization, but this patient should not be taken directly for endoscopy before the airway is secured."
            },
            {
              "id": "B",
              "text": "Option A: Start intravenous octreotide infusion is inappropriate because octreotide is appropriate early therapy for suspected variceal bleeding, but it does not address the patient\u0027s immediate airway threat from active hematemesis and somnolence."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous ceftriaxone prophylaxis is inappropriate because antibiotic prophylaxis is recommended in acute variceal hemorrhage, but airway protection takes priority when the patient is losing consciousness and aspirating blood."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly to urgent upper endoscopy is inappropriate because urgent endoscopy is needed after stabilization, but this patient should not be taken directly for endoscopy before the airway is secured."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place a balloon tamponade tube is inappropriate because balloon tamponade is a temporary rescue measure for uncontrolled bleeding when definitive therapy is not immediately successful or available; it is not the first next step here."
            },
            {
              "id": "B",
              "text": "Option A: Start intravenous octreotide infusion is inappropriate because octreotide is appropriate early therapy for suspected variceal bleeding, but it does not address the patient\u0027s immediate airway threat from active hematemesis and somnolence."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous ceftriaxone prophylaxis is inappropriate because antibiotic prophylaxis is recommended in acute variceal hemorrhage, but airway protection takes priority when the patient is losing consciousness and aspirating blood."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place a balloon tamponade tube is inappropriate because balloon tamponade is a temporary rescue measure for uncontrolled bleeding when definitive therapy is not immediately successful or available; it is not the first next step here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange emergent transjugular intrahepatic portosystemic shunt is inappropriate because tIPS is considered for refractory or high-risk variceal bleeding after initial stabilization and endoscopic management, not before airway protection."
            },
            {
              "id": "B",
              "text": "Option A: Start intravenous octreotide infusion is inappropriate because octreotide is appropriate early therapy for suspected variceal bleeding, but it does not address the patient\u0027s immediate airway threat from active hematemesis and somnolence."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous ceftriaxone prophylaxis is inappropriate because antibiotic prophylaxis is recommended in acute variceal hemorrhage, but airway protection takes priority when the patient is losing consciousness and aspirating blood."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange emergent transjugular intrahepatic portosystemic shunt is inappropriate because tIPS is considered for refractory or high-risk variceal bleeding after initial stabilization and endoscopic management, not before airway protection."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin continuous intravenous pantoprazole infusion is inappropriate because pantoprazole can be used empirically in undifferentiated upper GI bleeding, but it is not the most urgent intervention in a patient actively aspirating blood."
            },
            {
              "id": "B",
              "text": "Option A: Start intravenous octreotide infusion is inappropriate because octreotide is appropriate early therapy for suspected variceal bleeding, but it does not address the patient\u0027s immediate airway threat from active hematemesis and somnolence."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous ceftriaxone prophylaxis is inappropriate because antibiotic prophylaxis is recommended in acute variceal hemorrhage, but airway protection takes priority when the patient is losing consciousness and aspirating blood."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin continuous intravenous pantoprazole infusion is inappropriate because pantoprazole can be used empirically in undifferentiated upper GI bleeding, but it is not the most urgent intervention in a patient actively aspirating blood."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfuse packed red blood cells before any other intervention is inappropriate because packed red blood cells are often indicated, but transfusion does not supersede airway protection in a patient with active hematemesis and depressed consciousness."
            },
            {
              "id": "B",
              "text": "Option A: Start intravenous octreotide infusion is inappropriate because octreotide is appropriate early therapy for suspected variceal bleeding, but it does not address the patient\u0027s immediate airway threat from active hematemesis and somnolence."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous ceftriaxone prophylaxis is inappropriate because antibiotic prophylaxis is recommended in acute variceal hemorrhage, but airway protection takes priority when the patient is losing consciousness and aspirating blood."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfuse packed red blood cells before any other intervention is inappropriate because packed red blood cells are often indicated, but transfusion does not supersede airway protection in a patient with active hematemesis and depressed consciousness."
        }
      }
    },
    {
      "externalId": "free137-i001-pmr-age-risk-factor",
      "expectedHashes": {
        "ranaze_step3_uat": "e927e046b4db84606f3074f13121d7f350c267c46c23ae53fb773baac1f6c3d8",
        "ranaze_step3_prd": "e927e046b4db84606f3074f13121d7f350c267c46c23ae53fb773baac1f6c3d8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Female sex increases risk somewhat, but the condition is far more tightly linked to older age and is rare before age 50."
            },
            {
              "id": "B",
              "text": "Option C: History of osteoarthritis is inappropriate because osteoarthritis can coexist with polymyalgia rheumatica but does not meaningfully predispose to it."
            },
            {
              "id": "C",
              "text": "Option D: Use of levothyroxine is inappropriate because levothyroxine use does not cause this inflammatory syndrome and does not explain the elevated ESR and CRP with normal CK."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Female sex increases risk somewhat, but the condition is far more tightly linked to older age and is rare before age 50."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "History of osteoarthritis is inappropriate because osteoarthritis can coexist with polymyalgia rheumatica but does not meaningfully predispose to it."
            },
            {
              "id": "B",
              "text": "Option B: Female sex increases risk somewhat, but the condition is far more tightly linked to older age and is rare before age 50."
            },
            {
              "id": "C",
              "text": "Option D: Use of levothyroxine is inappropriate because levothyroxine use does not cause this inflammatory syndrome and does not explain the elevated ESR and CRP with normal CK."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "History of osteoarthritis is inappropriate because osteoarthritis can coexist with polymyalgia rheumatica but does not meaningfully predispose to it."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use of levothyroxine is inappropriate because levothyroxine use does not cause this inflammatory syndrome and does not explain the elevated ESR and CRP with normal CK."
            },
            {
              "id": "B",
              "text": "Option B: Female sex increases risk somewhat, but the condition is far more tightly linked to older age and is rare before age 50."
            },
            {
              "id": "C",
              "text": "Option C: History of osteoarthritis is inappropriate because osteoarthritis can coexist with polymyalgia rheumatica but does not meaningfully predispose to it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use of levothyroxine is inappropriate because levothyroxine use does not cause this inflammatory syndrome and does not explain the elevated ESR and CRP with normal CK."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prior occupation involving repetitive shoulder use is inappropriate because repetitive shoulder use may contribute to local overuse syndromes, not the systemic inflammatory pattern seen here."
            },
            {
              "id": "B",
              "text": "Option B: Female sex increases risk somewhat, but the condition is far more tightly linked to older age and is rare before age 50."
            },
            {
              "id": "C",
              "text": "Option C: History of osteoarthritis is inappropriate because osteoarthritis can coexist with polymyalgia rheumatica but does not meaningfully predispose to it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prior occupation involving repetitive shoulder use is inappropriate because repetitive shoulder use may contribute to local overuse syndromes, not the systemic inflammatory pattern seen here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mild normocytic anemia is inappropriate because mild anemia can accompany chronic inflammation but is a consequence of the disorder rather than a major predisposing risk factor."
            },
            {
              "id": "B",
              "text": "Option B: Female sex increases risk somewhat, but the condition is far more tightly linked to older age and is rare before age 50."
            },
            {
              "id": "C",
              "text": "Option C: History of osteoarthritis is inappropriate because osteoarthritis can coexist with polymyalgia rheumatica but does not meaningfully predispose to it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mild normocytic anemia is inappropriate because mild anemia can accompany chronic inflammation but is a consequence of the disorder rather than a major predisposing risk factor."
        }
      }
    },
    {
      "externalId": "free137-i008-first-recurrence-of-cdi-same-organism",
      "expectedHashes": {
        "ranaze_step3_uat": "1041334cc39e297fca0621ff467482c727606438dc9d7d007227f4c51af28397",
        "ranaze_step3_prd": "1041334cc39e297fca0621ff467482c727606438dc9d7d007227f4c51af28397"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Infection with a new enteric virus is inappropriate because a new enteric virus would not best explain recurrent positive testing for toxigenic C difficile shortly after documented CDI treatment."
            },
            {
              "id": "B",
              "text": "Option C: Reinfection from a household contact with a different organism is inappropriate because household reinfection is possible but is less likely than recurrence of the same infection in a patient with classic timing and repeat positive testing after recent CDI."
            },
            {
              "id": "C",
              "text": "Option D: Primary resistance of Clostridioides difficile to vancomycin is inappropriate because clinically important primary vancomycin resistance is not the usual explanation for a first recurrence after initial symptomatic resolution."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Infection with a new enteric virus is inappropriate because a new enteric virus would not best explain recurrent positive testing for toxigenic C difficile shortly after documented CDI treatment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reinfection from a household contact with a different organism is inappropriate because household reinfection is possible but is less likely than recurrence of the same infection in a patient with classic timing and repeat positive testing after recent CDI."
            },
            {
              "id": "B",
              "text": "Option A: Infection with a new enteric virus is inappropriate because a new enteric virus would not best explain recurrent positive testing for toxigenic C difficile shortly after documented CDI treatment."
            },
            {
              "id": "C",
              "text": "Option D: Primary resistance of Clostridioides difficile to vancomycin is inappropriate because clinically important primary vancomycin resistance is not the usual explanation for a first recurrence after initial symptomatic resolution."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reinfection from a household contact with a different organism is inappropriate because household reinfection is possible but is less likely than recurrence of the same infection in a patient with classic timing and repeat positive testing after recent CDI."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Primary resistance of Clostridioides difficile to vancomycin is inappropriate because clinically important primary vancomycin resistance is not the usual explanation for a first recurrence after initial symptomatic resolution."
            },
            {
              "id": "B",
              "text": "Option A: Infection with a new enteric virus is inappropriate because a new enteric virus would not best explain recurrent positive testing for toxigenic C difficile shortly after documented CDI treatment."
            },
            {
              "id": "C",
              "text": "Option C: Reinfection from a household contact with a different organism is inappropriate because household reinfection is possible but is less likely than recurrence of the same infection in a patient with classic timing and repeat positive testing after recent CDI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Primary resistance of Clostridioides difficile to vancomycin is inappropriate because clinically important primary vancomycin resistance is not the usual explanation for a first recurrence after initial symptomatic resolution."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Factitious diarrhea from laxative use is inappropriate because factitious diarrhea does not explain repeat positive testing for toxigenic C difficile in this clinical setting."
            },
            {
              "id": "B",
              "text": "Option A: Infection with a new enteric virus is inappropriate because a new enteric virus would not best explain recurrent positive testing for toxigenic C difficile shortly after documented CDI treatment."
            },
            {
              "id": "C",
              "text": "Option C: Reinfection from a household contact with a different organism is inappropriate because household reinfection is possible but is less likely than recurrence of the same infection in a patient with classic timing and repeat positive testing after recent CDI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Factitious diarrhea from laxative use is inappropriate because factitious diarrhea does not explain repeat positive testing for toxigenic C difficile in this clinical setting."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Undiagnosed inflammatory bowel disease is inappropriate because inflammatory bowel disease can cause diarrhea but does not best explain this pattern of recent CDI followed by classic short-interval recurrence."
            },
            {
              "id": "B",
              "text": "Option A: Infection with a new enteric virus is inappropriate because a new enteric virus would not best explain recurrent positive testing for toxigenic C difficile shortly after documented CDI treatment."
            },
            {
              "id": "C",
              "text": "Option C: Reinfection from a household contact with a different organism is inappropriate because household reinfection is possible but is less likely than recurrence of the same infection in a patient with classic timing and repeat positive testing after recent CDI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Undiagnosed inflammatory bowel disease is inappropriate because inflammatory bowel disease can cause diarrhea but does not best explain this pattern of recent CDI followed by classic short-interval recurrence."
        }
      }
    },
    {
      "externalId": "free137-i009-confidentiality-and-insurance-payment",
      "expectedHashes": {
        "ranaze_step3_uat": "b21b781518db36ab2b5495e3a52c34bc8037d71dd4077a1726265b112a241284",
        "ranaze_step3_prd": "b21b781518db36ab2b5495e3a52c34bc8037d71dd4077a1726265b112a241284"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His employer is inappropriate because an employer is not entitled to a patient\u0027s diagnosis merely because the insurance is employer-sponsored."
            },
            {
              "id": "B",
              "text": "Option B: His probation officer is inappropriate because probation status alone does not permit routine disclosure of a medical diagnosis."
            },
            {
              "id": "C",
              "text": "Option C: His spouse is inappropriate because a spouse is not automatically entitled to protected health information when the patient objects."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His employer is inappropriate because an employer is not entitled to a patient\u0027s diagnosis merely because the insurance is employer-sponsored."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His probation officer is inappropriate because probation status alone does not permit routine disclosure of a medical diagnosis."
            },
            {
              "id": "B",
              "text": "Option A: His employer is inappropriate because an employer is not entitled to a patient\u0027s diagnosis merely because the insurance is employer-sponsored."
            },
            {
              "id": "C",
              "text": "Option C: His spouse is inappropriate because a spouse is not automatically entitled to protected health information when the patient objects."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His probation officer is inappropriate because probation status alone does not permit routine disclosure of a medical diagnosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His spouse is inappropriate because a spouse is not automatically entitled to protected health information when the patient objects."
            },
            {
              "id": "B",
              "text": "Option A: His employer is inappropriate because an employer is not entitled to a patient\u0027s diagnosis merely because the insurance is employer-sponsored."
            },
            {
              "id": "C",
              "text": "Option B: His probation officer is inappropriate because probation status alone does not permit routine disclosure of a medical diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His spouse is inappropriate because a spouse is not automatically entitled to protected health information when the patient objects."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Local police is inappropriate because police do not receive routine access to diagnoses without a specific legal basis such as a court order or another applicable exception."
            },
            {
              "id": "B",
              "text": "Option A: His employer is inappropriate because an employer is not entitled to a patient\u0027s diagnosis merely because the insurance is employer-sponsored."
            },
            {
              "id": "C",
              "text": "Option B: His probation officer is inappropriate because probation status alone does not permit routine disclosure of a medical diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Local police is inappropriate because police do not receive routine access to diagnoses without a specific legal basis such as a court order or another applicable exception."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His landlord is inappropriate because a landlord has no routine role in treatment or payment for this encounter."
            },
            {
              "id": "B",
              "text": "Option A: His employer is inappropriate because an employer is not entitled to a patient\u0027s diagnosis merely because the insurance is employer-sponsored."
            },
            {
              "id": "C",
              "text": "Option B: His probation officer is inappropriate because probation status alone does not permit routine disclosure of a medical diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His landlord is inappropriate because a landlord has no routine role in treatment or payment for this encounter."
        }
      }
    },
    {
      "externalId": "free137-i010-emancipated-minor-consent-as-parent",
      "expectedHashes": {
        "ranaze_step3_uat": "2084c83ba7aa8375dc78f49291780d586d0b793355c5548afbc3e26e4683020a",
        "ranaze_step3_prd": "2084c83ba7aa8375dc78f49291780d586d0b793355c5548afbc3e26e4683020a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay care until one parent provides written consent is inappropriate because parental consent is not required when the patient is legally emancipated and capable of making medical decisions."
            },
            {
              "id": "B",
              "text": "Option C: Ask the adult relative who sometimes babysits her infant to consent is inappropriate because an adult relative who babysits the patient\u0027s child does not become the decision-maker for the patient\u0027s own medical care."
            },
            {
              "id": "C",
              "text": "Option D: Seek consent from the father of her infant is inappropriate because the father of her infant is not the decision-maker for this patient\u0027s medical care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay care until one parent provides written consent is inappropriate because parental consent is not required when the patient is legally emancipated and capable of making medical decisions."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the adult relative who sometimes babysits her infant to consent is inappropriate because an adult relative who babysits the patient\u0027s child does not become the decision-maker for the patient\u0027s own medical care."
            },
            {
              "id": "B",
              "text": "Option B: Delay care until one parent provides written consent is inappropriate because parental consent is not required when the patient is legally emancipated and capable of making medical decisions."
            },
            {
              "id": "C",
              "text": "Option D: Seek consent from the father of her infant is inappropriate because the father of her infant is not the decision-maker for this patient\u0027s medical care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the adult relative who sometimes babysits her infant to consent is inappropriate because an adult relative who babysits the patient\u0027s child does not become the decision-maker for the patient\u0027s own medical care."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Seek consent from the father of her infant is inappropriate because the father of her infant is not the decision-maker for this patient\u0027s medical care."
            },
            {
              "id": "B",
              "text": "Option B: Delay care until one parent provides written consent is inappropriate because parental consent is not required when the patient is legally emancipated and capable of making medical decisions."
            },
            {
              "id": "C",
              "text": "Option C: Ask the adult relative who sometimes babysits her infant to consent is inappropriate because an adult relative who babysits the patient\u0027s child does not become the decision-maker for the patient\u0027s own medical care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Seek consent from the father of her infant is inappropriate because the father of her infant is not the decision-maker for this patient\u0027s medical care."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a court order before examination is inappropriate because a new court order is unnecessary because the stem already provides a certified copy of a court order declaring emancipation."
            },
            {
              "id": "B",
              "text": "Option B: Delay care until one parent provides written consent is inappropriate because parental consent is not required when the patient is legally emancipated and capable of making medical decisions."
            },
            {
              "id": "C",
              "text": "Option C: Ask the adult relative who sometimes babysits her infant to consent is inappropriate because an adult relative who babysits the patient\u0027s child does not become the decision-maker for the patient\u0027s own medical care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a court order before examination is inappropriate because a new court order is unnecessary because the stem already provides a certified copy of a court order declaring emancipation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Require consent from two physicians because she is younger than 18 years is inappropriate because there is no general rule requiring two physicians to authorize routine treatment for a legally emancipated minor."
            },
            {
              "id": "B",
              "text": "Option B: Delay care until one parent provides written consent is inappropriate because parental consent is not required when the patient is legally emancipated and capable of making medical decisions."
            },
            {
              "id": "C",
              "text": "Option C: Ask the adult relative who sometimes babysits her infant to consent is inappropriate because an adult relative who babysits the patient\u0027s child does not become the decision-maker for the patient\u0027s own medical care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Require consent from two physicians because she is younger than 18 years is inappropriate because there is no general rule requiring two physicians to authorize routine treatment for a legally emancipated minor."
        }
      }
    },
    {
      "externalId": "free137-i011-benzodiazepine-respiratory-depression-after-status-seizure-treatment",
      "expectedHashes": {
        "ranaze_step3_uat": "746718008ff136bfd220ee8c3d62d6606aaf3bafd6a0c715abde5ee56a8087fe",
        "ranaze_step3_prd": "746718008ff136bfd220ee8c3d62d6606aaf3bafd6a0c715abde5ee56a8087fe"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Upper airway foreign-body obstruction is inappropriate because a foreign-body obstruction is less likely than a medication effect given the immediate temporal relationship to repeated diazepam administration and shallow respirations."
            },
            {
              "id": "B",
              "text": "Option B: Bacterial meningitis is inappropriate because meningitis can cause fever and seizures, but it does not best explain sudden hypoventilation within minutes of diazepam administration."
            },
            {
              "id": "C",
              "text": "Option D: Ongoing nonconvulsive status epilepticus is inappropriate because persistent seizure activity can impair consciousness, but the immediate shallow breathing after diazepam more strongly suggests medication effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Upper airway foreign-body obstruction is inappropriate because a foreign-body obstruction is less likely than a medication effect given the immediate temporal relationship to repeated diazepam administration and shallow respirations."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bacterial meningitis is inappropriate because meningitis can cause fever and seizures, but it does not best explain sudden hypoventilation within minutes of diazepam administration."
            },
            {
              "id": "B",
              "text": "Option A: Upper airway foreign-body obstruction is inappropriate because a foreign-body obstruction is less likely than a medication effect given the immediate temporal relationship to repeated diazepam administration and shallow respirations."
            },
            {
              "id": "C",
              "text": "Option D: Ongoing nonconvulsive status epilepticus is inappropriate because persistent seizure activity can impair consciousness, but the immediate shallow breathing after diazepam more strongly suggests medication effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bacterial meningitis is inappropriate because meningitis can cause fever and seizures, but it does not best explain sudden hypoventilation within minutes of diazepam administration."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ongoing nonconvulsive status epilepticus is inappropriate because persistent seizure activity can impair consciousness, but the immediate shallow breathing after diazepam more strongly suggests medication effect."
            },
            {
              "id": "B",
              "text": "Option A: Upper airway foreign-body obstruction is inappropriate because a foreign-body obstruction is less likely than a medication effect given the immediate temporal relationship to repeated diazepam administration and shallow respirations."
            },
            {
              "id": "C",
              "text": "Option B: Bacterial meningitis is inappropriate because meningitis can cause fever and seizures, but it does not best explain sudden hypoventilation within minutes of diazepam administration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ongoing nonconvulsive status epilepticus is inappropriate because persistent seizure activity can impair consciousness, but the immediate shallow breathing after diazepam more strongly suggests medication effect."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Viral encephalitis is inappropriate because encephalitis can cause fever and seizures, but it is less likely to produce abrupt respiratory depression exactly after additional diazepam dosing."
            },
            {
              "id": "B",
              "text": "Option A: Upper airway foreign-body obstruction is inappropriate because a foreign-body obstruction is less likely than a medication effect given the immediate temporal relationship to repeated diazepam administration and shallow respirations."
            },
            {
              "id": "C",
              "text": "Option B: Bacterial meningitis is inappropriate because meningitis can cause fever and seizures, but it does not best explain sudden hypoventilation within minutes of diazepam administration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Viral encephalitis is inappropriate because encephalitis can cause fever and seizures, but it is less likely to produce abrupt respiratory depression exactly after additional diazepam dosing."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspiration of gastric contents is inappropriate because aspiration can cause hypoxemia, but the stem emphasizes shallow respirations immediately after diazepam administration, which points more strongly to central respiratory depression."
            },
            {
              "id": "B",
              "text": "Option A: Upper airway foreign-body obstruction is inappropriate because a foreign-body obstruction is less likely than a medication effect given the immediate temporal relationship to repeated diazepam administration and shallow respirations."
            },
            {
              "id": "C",
              "text": "Option B: Bacterial meningitis is inappropriate because meningitis can cause fever and seizures, but it does not best explain sudden hypoventilation within minutes of diazepam administration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspiration of gastric contents is inappropriate because aspiration can cause hypoxemia, but the stem emphasizes shallow respirations immediately after diazepam administration, which points more strongly to central respiratory depression."
        }
      }
    },
    {
      "externalId": "free137-i012-ptsd-assessment-with-open-ended-narrative",
      "expectedHashes": {
        "ranaze_step3_uat": "46f47583665f855d4ff71b75a71b5e21569de47b3487434461aca679ec9fa84d",
        "ranaze_step3_prd": "46f47583665f855d4ff71b75a71b5e21569de47b3487434461aca679ec9fa84d"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a sedative-hypnotic and then reinterview him is inappropriate because drug-facilitated interviewing is not an accepted method for confirming PTSD and can distort assessment."
            },
            {
              "id": "B",
              "text": "Option C: Interview him under hypnosis is inappropriate because hypnosis is not a standard diagnostic method for confirming PTSD."
            },
            {
              "id": "C",
              "text": "Option D: Rely primarily on whether he makes direct eye contact is inappropriate because eye contact is not a reliable method for establishing whether PTSD criteria are met."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a sedative-hypnotic and then reinterview him is inappropriate because drug-facilitated interviewing is not an accepted method for confirming PTSD and can distort assessment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Interview him under hypnosis is inappropriate because hypnosis is not a standard diagnostic method for confirming PTSD."
            },
            {
              "id": "B",
              "text": "Option A: Administer a sedative-hypnotic and then reinterview him is inappropriate because drug-facilitated interviewing is not an accepted method for confirming PTSD and can distort assessment."
            },
            {
              "id": "C",
              "text": "Option D: Rely primarily on whether he makes direct eye contact is inappropriate because eye contact is not a reliable method for establishing whether PTSD criteria are met."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Interview him under hypnosis is inappropriate because hypnosis is not a standard diagnostic method for confirming PTSD."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Rely primarily on whether he makes direct eye contact is inappropriate because eye contact is not a reliable method for establishing whether PTSD criteria are met."
            },
            {
              "id": "B",
              "text": "Option A: Administer a sedative-hypnotic and then reinterview him is inappropriate because drug-facilitated interviewing is not an accepted method for confirming PTSD and can distort assessment."
            },
            {
              "id": "C",
              "text": "Option C: Interview him under hypnosis is inappropriate because hypnosis is not a standard diagnostic method for confirming PTSD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Rely primarily on whether he makes direct eye contact is inappropriate because eye contact is not a reliable method for establishing whether PTSD criteria are met."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tell him he appears to be malingering and watch his reaction is inappropriate because accusing the patient of malingering is not the appropriate first step when diagnostic clarification has not yet been completed."
            },
            {
              "id": "B",
              "text": "Option A: Administer a sedative-hypnotic and then reinterview him is inappropriate because drug-facilitated interviewing is not an accepted method for confirming PTSD and can distort assessment."
            },
            {
              "id": "C",
              "text": "Option C: Interview him under hypnosis is inappropriate because hypnosis is not a standard diagnostic method for confirming PTSD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tell him he appears to be malingering and watch his reaction is inappropriate because accusing the patient of malingering is not the appropriate first step when diagnostic clarification has not yet been completed."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Certify the diagnosis based on his written symptom list alone is inappropriate because a written symptom list may be useful background information, but it does not substitute for a diagnostic interview."
            },
            {
              "id": "B",
              "text": "Option A: Administer a sedative-hypnotic and then reinterview him is inappropriate because drug-facilitated interviewing is not an accepted method for confirming PTSD and can distort assessment."
            },
            {
              "id": "C",
              "text": "Option C: Interview him under hypnosis is inappropriate because hypnosis is not a standard diagnostic method for confirming PTSD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Certify the diagnosis based on his written symptom list alone is inappropriate because a written symptom list may be useful background information, but it does not substitute for a diagnostic interview."
        }
      }
    },
    {
      "externalId": "free137-i013-nnt-variceal-rebleeding-trial",
      "expectedHashes": {
        "ranaze_step3_uat": "4078a2dade16b6b81511b39d4475ef6ca4a04bac20f82c4a696884c25299a139",
        "ranaze_step3_prd": "4078a2dade16b6b81511b39d4475ef6ca4a04bac20f82c4a696884c25299a139"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An answer of 2 would require a 50% absolute risk reduction, which is much larger than the 20% difference reported."
            },
            {
              "id": "B",
              "text": "Option B: An answer of 3 would correspond to an absolute risk reduction of about 33%, not the reported 20%."
            },
            {
              "id": "C",
              "text": "Option C: An answer of 4 would correspond to an absolute risk reduction of 25%, which is still larger than the reported difference."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An answer of 2 would require a 50% absolute risk reduction, which is much larger than the 20% difference reported."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An answer of 3 would correspond to an absolute risk reduction of about 33%, not the reported 20%."
            },
            {
              "id": "B",
              "text": "Option A: An answer of 2 would require a 50% absolute risk reduction, which is much larger than the 20% difference reported."
            },
            {
              "id": "C",
              "text": "Option C: An answer of 4 would correspond to an absolute risk reduction of 25%, which is still larger than the reported difference."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An answer of 3 would correspond to an absolute risk reduction of about 33%, not the reported 20%."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An answer of 4 would correspond to an absolute risk reduction of 25%, which is still larger than the reported difference."
            },
            {
              "id": "B",
              "text": "Option A: An answer of 2 would require a 50% absolute risk reduction, which is much larger than the 20% difference reported."
            },
            {
              "id": "C",
              "text": "Option B: An answer of 3 would correspond to an absolute risk reduction of about 33%, not the reported 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An answer of 4 would correspond to an absolute risk reduction of 25%, which is still larger than the reported difference."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An answer of 6 would correspond to an absolute risk reduction of about 17%, which is smaller than the reported difference."
            },
            {
              "id": "B",
              "text": "Option A: An answer of 2 would require a 50% absolute risk reduction, which is much larger than the 20% difference reported."
            },
            {
              "id": "C",
              "text": "Option B: An answer of 3 would correspond to an absolute risk reduction of about 33%, not the reported 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An answer of 6 would correspond to an absolute risk reduction of about 17%, which is smaller than the reported difference."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An answer of 10 would correspond to an absolute risk reduction of 10%, only half of the reported difference."
            },
            {
              "id": "B",
              "text": "Option A: An answer of 2 would require a 50% absolute risk reduction, which is much larger than the 20% difference reported."
            },
            {
              "id": "C",
              "text": "Option B: An answer of 3 would correspond to an absolute risk reduction of about 33%, not the reported 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An answer of 10 would correspond to an absolute risk reduction of 10%, only half of the reported difference."
        }
      }
    },
    {
      "externalId": "free137-i014-generalizability-specialty-center-intervention",
      "expectedHashes": {
        "ranaze_step3_uat": "585932f692e2a71fe5b0080551a9f49d465cb1ae70b813fccfa5564f28c96ce1",
        "ranaze_step3_prd": "585932f692e2a71fe5b0080551a9f49d465cb1ae70b813fccfa5564f28c96ce1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Allocation concealment was used is inappropriate because allocation concealment strengthens internal validity but does not explain why the results may not transfer to hospitals with different resources."
            },
            {
              "id": "B",
              "text": "Option C: Follow-up lasted only 90 days is inappropriate because short follow-up can limit long-term outcome assessment, but it is not the main reason these findings may not apply to many hospitals."
            },
            {
              "id": "C",
              "text": "Option D: Participants and clinicians were not blinded is inappropriate because lack of blinding is mainly an internal-validity concern, not the strongest limitation on generalizability here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Allocation concealment was used is inappropriate because allocation concealment strengthens internal validity but does not explain why the results may not transfer to hospitals with different resources."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Follow-up lasted only 90 days is inappropriate because short follow-up can limit long-term outcome assessment, but it is not the main reason these findings may not apply to many hospitals."
            },
            {
              "id": "B",
              "text": "Option A: Allocation concealment was used is inappropriate because allocation concealment strengthens internal validity but does not explain why the results may not transfer to hospitals with different resources."
            },
            {
              "id": "C",
              "text": "Option D: Participants and clinicians were not blinded is inappropriate because lack of blinding is mainly an internal-validity concern, not the strongest limitation on generalizability here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Follow-up lasted only 90 days is inappropriate because short follow-up can limit long-term outcome assessment, but it is not the main reason these findings may not apply to many hospitals."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Participants and clinicians were not blinded is inappropriate because lack of blinding is mainly an internal-validity concern, not the strongest limitation on generalizability here."
            },
            {
              "id": "B",
              "text": "Option A: Allocation concealment was used is inappropriate because allocation concealment strengthens internal validity but does not explain why the results may not transfer to hospitals with different resources."
            },
            {
              "id": "C",
              "text": "Option C: Follow-up lasted only 90 days is inappropriate because short follow-up can limit long-term outcome assessment, but it is not the main reason these findings may not apply to many hospitals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Participants and clinicians were not blinded is inappropriate because lack of blinding is mainly an internal-validity concern, not the strongest limitation on generalizability here."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Randomization cannot address unmeasured confounding is inappropriate because randomization is specifically used to reduce confounding between study groups; the stem instead emphasizes differences between the trial setting and the target setting."
            },
            {
              "id": "B",
              "text": "Option A: Allocation concealment was used is inappropriate because allocation concealment strengthens internal validity but does not explain why the results may not transfer to hospitals with different resources."
            },
            {
              "id": "C",
              "text": "Option C: Follow-up lasted only 90 days is inappropriate because short follow-up can limit long-term outcome assessment, but it is not the main reason these findings may not apply to many hospitals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Randomization cannot address unmeasured confounding is inappropriate because randomization is specifically used to reduce confounding between study groups; the stem instead emphasizes differences between the trial setting and the target setting."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The analysis used intention to treat is inappropriate because intention-to-treat analysis is generally a strength of randomized trials and does not explain poor applicability to hospitals without the same capabilities."
            },
            {
              "id": "B",
              "text": "Option A: Allocation concealment was used is inappropriate because allocation concealment strengthens internal validity but does not explain why the results may not transfer to hospitals with different resources."
            },
            {
              "id": "C",
              "text": "Option C: Follow-up lasted only 90 days is inappropriate because short follow-up can limit long-term outcome assessment, but it is not the main reason these findings may not apply to many hospitals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The analysis used intention to treat is inappropriate because intention-to-treat analysis is generally a strength of randomized trials and does not explain poor applicability to hospitals without the same capabilities."
        }
      }
    },
    {
      "externalId": "free137-i015-table-interpretation-variceal-readmissions",
      "expectedHashes": {
        "ranaze_step3_uat": "ff982735dc3e77d4e054f7f2d6df673be1f54561a6799e1deea8952582dce494",
        "ranaze_step3_prd": "ff982735dc3e77d4e054f7f2d6df673be1f54561a6799e1deea8952582dce494"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The class A confidence interval excludes no difference in survival is inappropriate because this is incorrect because the class A 95% confidence interval runs from -0.3 to 0.7 years, which includes 0."
            },
            {
              "id": "B",
              "text": "Option C: Within the early shunt group, median survival was statistically significantly shorter in class C than in class B is inappropriate because this is not supported because the table reports between-group estimates within each class, not a formal statistical comparison between class C and class B within one treatment arm."
            },
            {
              "id": "C",
              "text": "Option D: Randomization failed because survival differed across Child-Turcotte-Pugh classes is inappropriate because different survival across severity classes reflects different baseline prognosis, not failed randomization, especially when baseline characteristics were similar between groups."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The class A confidence interval excludes no difference in survival is inappropriate because this is incorrect because the class A 95% confidence interval runs from -0.3 to 0.7 years, which includes 0."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Within the early shunt group, median survival was statistically significantly shorter in class C than in class B is inappropriate because this is not supported because the table reports between-group estimates within each class, not a formal statistical comparison between class C and class B within one treatment arm."
            },
            {
              "id": "B",
              "text": "Option A: The class A confidence interval excludes no difference in survival is inappropriate because this is incorrect because the class A 95% confidence interval runs from -0.3 to 0.7 years, which includes 0."
            },
            {
              "id": "C",
              "text": "Option D: Randomization failed because survival differed across Child-Turcotte-Pugh classes is inappropriate because different survival across severity classes reflects different baseline prognosis, not failed randomization, especially when baseline characteristics were similar between groups."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Within the early shunt group, median survival was statistically significantly shorter in class C than in class B is inappropriate because this is not supported because the table reports between-group estimates within each class, not a formal statistical comparison between class C and class B within one treatment arm."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Randomization failed because survival differed across Child-Turcotte-Pugh classes is inappropriate because different survival across severity classes reflects different baseline prognosis, not failed randomization, especially when baseline characteristics were similar between groups."
            },
            {
              "id": "B",
              "text": "Option A: The class A confidence interval excludes no difference in survival is inappropriate because this is incorrect because the class A 95% confidence interval runs from -0.3 to 0.7 years, which includes 0."
            },
            {
              "id": "C",
              "text": "Option C: Within the early shunt group, median survival was statistically significantly shorter in class C than in class B is inappropriate because this is not supported because the table reports between-group estimates within each class, not a formal statistical comparison between class C and class B within one treatment arm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Randomization failed because survival differed across Child-Turcotte-Pugh classes is inappropriate because different survival across severity classes reflects different baseline prognosis, not failed randomization, especially when baseline characteristics were similar between groups."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Only class A patients benefited from the early shunt strategy is inappropriate because this is incorrect because class A does not show an exclusive benefit; its confidence interval includes no difference."
            },
            {
              "id": "B",
              "text": "Option A: The class A confidence interval excludes no difference in survival is inappropriate because this is incorrect because the class A 95% confidence interval runs from -0.3 to 0.7 years, which includes 0."
            },
            {
              "id": "C",
              "text": "Option C: Within the early shunt group, median survival was statistically significantly shorter in class C than in class B is inappropriate because this is not supported because the table reports between-group estimates within each class, not a formal statistical comparison between class C and class B within one treatment arm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Only class A patients benefited from the early shunt strategy is inappropriate because this is incorrect because class A does not show an exclusive benefit; its confidence interval includes no difference."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Median survival was identical across all Child-Turcotte-Pugh classes is inappropriate because this is incorrect because the reported median survivals differ across classes."
            },
            {
              "id": "B",
              "text": "Option A: The class A confidence interval excludes no difference in survival is inappropriate because this is incorrect because the class A 95% confidence interval runs from -0.3 to 0.7 years, which includes 0."
            },
            {
              "id": "C",
              "text": "Option C: Within the early shunt group, median survival was statistically significantly shorter in class C than in class B is inappropriate because this is not supported because the table reports between-group estimates within each class, not a formal statistical comparison between class C and class B within one treatment arm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Median survival was identical across all Child-Turcotte-Pugh classes is inappropriate because this is incorrect because the reported median survivals differ across classes."
        }
      }
    },
    {
      "externalId": "free137-i016-sickle-cell-falsely-low-a1c",
      "expectedHashes": {
        "ranaze_step3_uat": "4476d5d0def4dbf3646a08ce5548b8ed0fc67f0b5d2d92857a9d58fa2693c64a",
        "ranaze_step3_prd": "4476d5d0def4dbf3646a08ce5548b8ed0fc67f0b5d2d92857a9d58fa2693c64a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Iron deficiency is lowering the hemoglobin A1c is inappropriate because iron deficiency tends to raise, not lower, hemoglobin A1c values, and her reticulocytosis is more consistent with hemolysis than iron deficiency."
            },
            {
              "id": "B",
              "text": "Option B: Her day-to-day glucose control is substantially better than the home log suggests is inappropriate because the repeatedly elevated home glucose readings argue against markedly better control than recorded."
            },
            {
              "id": "C",
              "text": "Option C: Her glucometer is reading falsely high and should be replaced is inappropriate because a device problem is less likely than a known biologic limitation of A1c in HbSS disease, especially with anemia and reticulocytosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Iron deficiency is lowering the hemoglobin A1c is inappropriate because iron deficiency tends to raise, not lower, hemoglobin A1c values, and her reticulocytosis is more consistent with hemolysis than iron deficiency."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Her day-to-day glucose control is substantially better than the home log suggests is inappropriate because the repeatedly elevated home glucose readings argue against markedly better control than recorded."
            },
            {
              "id": "B",
              "text": "Option A: Iron deficiency is lowering the hemoglobin A1c is inappropriate because iron deficiency tends to raise, not lower, hemoglobin A1c values, and her reticulocytosis is more consistent with hemolysis than iron deficiency."
            },
            {
              "id": "C",
              "text": "Option C: Her glucometer is reading falsely high and should be replaced is inappropriate because a device problem is less likely than a known biologic limitation of A1c in HbSS disease, especially with anemia and reticulocytosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Her day-to-day glucose control is substantially better than the home log suggests is inappropriate because the repeatedly elevated home glucose readings argue against markedly better control than recorded."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Her glucometer is reading falsely high and should be replaced is inappropriate because a device problem is less likely than a known biologic limitation of A1c in HbSS disease, especially with anemia and reticulocytosis."
            },
            {
              "id": "B",
              "text": "Option A: Iron deficiency is lowering the hemoglobin A1c is inappropriate because iron deficiency tends to raise, not lower, hemoglobin A1c values, and her reticulocytosis is more consistent with hemolysis than iron deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Her day-to-day glucose control is substantially better than the home log suggests is inappropriate because the repeatedly elevated home glucose readings argue against markedly better control than recorded."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Her glucometer is reading falsely high and should be replaced is inappropriate because a device problem is less likely than a known biologic limitation of A1c in HbSS disease, especially with anemia and reticulocytosis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The hemoglobin A1c should be dismissed as random laboratory error is inappropriate because random laboratory error is less likely than a predictable distortion caused by altered red-cell turnover in sickle cell disease."
            },
            {
              "id": "B",
              "text": "Option A: Iron deficiency is lowering the hemoglobin A1c is inappropriate because iron deficiency tends to raise, not lower, hemoglobin A1c values, and her reticulocytosis is more consistent with hemolysis than iron deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Her day-to-day glucose control is substantially better than the home log suggests is inappropriate because the repeatedly elevated home glucose readings argue against markedly better control than recorded."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The hemoglobin A1c should be dismissed as random laboratory error is inappropriate because random laboratory error is less likely than a predictable distortion caused by altered red-cell turnover in sickle cell disease."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A recent infection is transiently elevating her home glucose values is inappropriate because transient hyperglycemia from infection would not explain 3 months of consistently elevated home readings with a disproportionately low A1c."
            },
            {
              "id": "B",
              "text": "Option A: Iron deficiency is lowering the hemoglobin A1c is inappropriate because iron deficiency tends to raise, not lower, hemoglobin A1c values, and her reticulocytosis is more consistent with hemolysis than iron deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Her day-to-day glucose control is substantially better than the home log suggests is inappropriate because the repeatedly elevated home glucose readings argue against markedly better control than recorded."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A recent infection is transiently elevating her home glucose values is inappropriate because transient hyperglycemia from infection would not explain 3 months of consistently elevated home readings with a disproportionately low A1c."
        }
      }
    },
    {
      "externalId": "free137-i017-proximal-weakness-polymyositis",
      "expectedHashes": {
        "ranaze_step3_uat": "4ccc11fe5b606907ec4785c5e1472da62e5060804b5b0d40398fb0366e1e84ef",
        "ranaze_step3_prd": "4ccc11fe5b606907ec4785c5e1472da62e5060804b5b0d40398fb0366e1e84ef"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fibromyalgia causes widespread pain and tenderness but does not cause objective proximal weakness with marked creatine kinase elevation."
            },
            {
              "id": "B",
              "text": "Option B: Hypothyroid myopathy can cause weakness and CK elevation, but her thyroid-stimulating hormone is normal."
            },
            {
              "id": "C",
              "text": "Option C: Myasthenia gravis causes fatigable weakness, often with ocular or bulbar involvement, and does not typically elevate creatine kinase markedly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fibromyalgia causes widespread pain and tenderness but does not cause objective proximal weakness with marked creatine kinase elevation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hypothyroid myopathy can cause weakness and CK elevation, but her thyroid-stimulating hormone is normal."
            },
            {
              "id": "B",
              "text": "Option A: Fibromyalgia causes widespread pain and tenderness but does not cause objective proximal weakness with marked creatine kinase elevation."
            },
            {
              "id": "C",
              "text": "Option C: Myasthenia gravis causes fatigable weakness, often with ocular or bulbar involvement, and does not typically elevate creatine kinase markedly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hypothyroid myopathy can cause weakness and CK elevation, but her thyroid-stimulating hormone is normal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Myasthenia gravis causes fatigable weakness, often with ocular or bulbar involvement, and does not typically elevate creatine kinase markedly."
            },
            {
              "id": "B",
              "text": "Option A: Fibromyalgia causes widespread pain and tenderness but does not cause objective proximal weakness with marked creatine kinase elevation."
            },
            {
              "id": "C",
              "text": "Option B: Hypothyroid myopathy can cause weakness and CK elevation, but her thyroid-stimulating hormone is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Myasthenia gravis causes fatigable weakness, often with ocular or bulbar involvement, and does not typically elevate creatine kinase markedly."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lambert-Eaton myasthenic syndrome is inappropriate because lambert-Eaton syndrome usually presents with proximal weakness but is associated with reduced reflexes, autonomic symptoms, and not marked muscle-enzyme elevation."
            },
            {
              "id": "B",
              "text": "Option A: Fibromyalgia causes widespread pain and tenderness but does not cause objective proximal weakness with marked creatine kinase elevation."
            },
            {
              "id": "C",
              "text": "Option B: Hypothyroid myopathy can cause weakness and CK elevation, but her thyroid-stimulating hormone is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lambert-Eaton myasthenic syndrome is inappropriate because lambert-Eaton syndrome usually presents with proximal weakness but is associated with reduced reflexes, autonomic symptoms, and not marked muscle-enzyme elevation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Systemic sclerosis may cause skin thickening and Raynaud phenomenon; it does not best explain isolated inflammatory proximal myopathy here."
            },
            {
              "id": "B",
              "text": "Option A: Fibromyalgia causes widespread pain and tenderness but does not cause objective proximal weakness with marked creatine kinase elevation."
            },
            {
              "id": "C",
              "text": "Option B: Hypothyroid myopathy can cause weakness and CK elevation, but her thyroid-stimulating hormone is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Systemic sclerosis may cause skin thickening and Raynaud phenomenon; it does not best explain isolated inflammatory proximal myopathy here."
        }
      }
    },
    {
      "externalId": "free137-i018-posthoc-subgroup-validity",
      "expectedHashes": {
        "ranaze_step3_uat": "a21e3f3b698505f9c3097591aaa90deecf8af085fa796db2e2166fc8ee95139e",
        "ranaze_step3_prd": "a21e3f3b698505f9c3097591aaa90deecf8af085fa796db2e2166fc8ee95139e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Randomization probably favored that subgroup at baseline is inappropriate because there is no information that randomization favored that subgroup, and this is not the main reason to question the finding."
            },
            {
              "id": "B",
              "text": "Option B: The infection is more common in that subgroup is inappropriate because a higher baseline disease frequency in a subgroup does not by itself invalidate a subgroup treatment effect."
            },
            {
              "id": "C",
              "text": "Option C: The trial was multicenter is inappropriate because a multicenter design is not the reason this particular subgroup claim is less reliable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Randomization probably favored that subgroup at baseline is inappropriate because there is no information that randomization favored that subgroup, and this is not the main reason to question the finding."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The infection is more common in that subgroup is inappropriate because a higher baseline disease frequency in a subgroup does not by itself invalidate a subgroup treatment effect."
            },
            {
              "id": "B",
              "text": "Option A: Randomization probably favored that subgroup at baseline is inappropriate because there is no information that randomization favored that subgroup, and this is not the main reason to question the finding."
            },
            {
              "id": "C",
              "text": "Option C: The trial was multicenter is inappropriate because a multicenter design is not the reason this particular subgroup claim is less reliable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The infection is more common in that subgroup is inappropriate because a higher baseline disease frequency in a subgroup does not by itself invalidate a subgroup treatment effect."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The trial was multicenter is inappropriate because a multicenter design is not the reason this particular subgroup claim is less reliable."
            },
            {
              "id": "B",
              "text": "Option A: Randomization probably favored that subgroup at baseline is inappropriate because there is no information that randomization favored that subgroup, and this is not the main reason to question the finding."
            },
            {
              "id": "C",
              "text": "Option B: The infection is more common in that subgroup is inappropriate because a higher baseline disease frequency in a subgroup does not by itself invalidate a subgroup treatment effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The trial was multicenter is inappropriate because a multicenter design is not the reason this particular subgroup claim is less reliable."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The sample size was too large is inappropriate because a large sample does not explain why an exploratory subgroup signal is questionable."
            },
            {
              "id": "B",
              "text": "Option A: Randomization probably favored that subgroup at baseline is inappropriate because there is no information that randomization favored that subgroup, and this is not the main reason to question the finding."
            },
            {
              "id": "C",
              "text": "Option B: The infection is more common in that subgroup is inappropriate because a higher baseline disease frequency in a subgroup does not by itself invalidate a subgroup treatment effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The sample size was too large is inappropriate because a large sample does not explain why an exploratory subgroup signal is questionable."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The finding most likely reflects a type II error is inappropriate because a type II error is a false negative, whereas the concern here is a false-positive subgroup inference."
            },
            {
              "id": "B",
              "text": "Option A: Randomization probably favored that subgroup at baseline is inappropriate because there is no information that randomization favored that subgroup, and this is not the main reason to question the finding."
            },
            {
              "id": "C",
              "text": "Option B: The infection is more common in that subgroup is inappropriate because a higher baseline disease frequency in a subgroup does not by itself invalidate a subgroup treatment effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The finding most likely reflects a type II error is inappropriate because a type II error is a false negative, whereas the concern here is a false-positive subgroup inference."
        }
      }
    },
    {
      "externalId": "free137-i019-inguinal-node-vulvar-source",
      "expectedHashes": {
        "ranaze_step3_uat": "061ea414c6926d16b426693967a70eadaa4e76d69c29373c81d24664a52bd8cf",
        "ranaze_step3_prd": "061ea414c6926d16b426693967a70eadaa4e76d69c29373c81d24664a52bd8cf"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The cervix primarily drains to pelvic lymph nodes, not superficial inguinal nodes."
            },
            {
              "id": "B",
              "text": "Option B: The endometrium drains mainly to pelvic and para-aortic nodes rather than superficial inguinal nodes."
            },
            {
              "id": "C",
              "text": "Option C: Ovary is inappropriate because the ovaries drain to para-aortic nodes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The cervix primarily drains to pelvic lymph nodes, not superficial inguinal nodes."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The endometrium drains mainly to pelvic and para-aortic nodes rather than superficial inguinal nodes."
            },
            {
              "id": "B",
              "text": "Option A: The cervix primarily drains to pelvic lymph nodes, not superficial inguinal nodes."
            },
            {
              "id": "C",
              "text": "Option C: Ovary is inappropriate because the ovaries drain to para-aortic nodes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The endometrium drains mainly to pelvic and para-aortic nodes rather than superficial inguinal nodes."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ovary is inappropriate because the ovaries drain to para-aortic nodes."
            },
            {
              "id": "B",
              "text": "Option A: The cervix primarily drains to pelvic lymph nodes, not superficial inguinal nodes."
            },
            {
              "id": "C",
              "text": "Option B: The endometrium drains mainly to pelvic and para-aortic nodes rather than superficial inguinal nodes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ovary is inappropriate because the ovaries drain to para-aortic nodes."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The upper vagina primarily drains to pelvic nodes."
            },
            {
              "id": "B",
              "text": "Option A: The cervix primarily drains to pelvic lymph nodes, not superficial inguinal nodes."
            },
            {
              "id": "C",
              "text": "Option B: The endometrium drains mainly to pelvic and para-aortic nodes rather than superficial inguinal nodes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The upper vagina primarily drains to pelvic nodes."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The uterine fundus drains chiefly to para-aortic nodes, with some drainage along the round ligament, but it does not best fit this superficial vulvar lesion and local node pattern."
            },
            {
              "id": "B",
              "text": "Option A: The cervix primarily drains to pelvic lymph nodes, not superficial inguinal nodes."
            },
            {
              "id": "C",
              "text": "Option B: The endometrium drains mainly to pelvic and para-aortic nodes rather than superficial inguinal nodes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The uterine fundus drains chiefly to para-aortic nodes, with some drainage along the round ligament, but it does not best fit this superficial vulvar lesion and local node pattern."
        }
      }
    },
    {
      "externalId": "free137-i020-inferior-stemi-text-ecg",
      "expectedHashes": {
        "ranaze_step3_uat": "861488fb68018192067e0d255c69ad92e08ec26f8f2143803589be91fb5794ad",
        "ranaze_step3_prd": "861488fb68018192067e0d255c69ad92e08ec26f8f2143803589be91fb5794ad"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute pericarditis is inappropriate because pericarditis usually causes pleuritic pain and diffuse ST elevation with PR depression rather than focal inferior ST elevation with reciprocal changes."
            },
            {
              "id": "B",
              "text": "Option B: Hyperventilation syndrome does not produce localized ST-elevation changes with reciprocal depression."
            },
            {
              "id": "C",
              "text": "Option D: Pulmonary embolism may cause dyspnea and chest discomfort, but this ECG pattern is much more consistent with STEMI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute pericarditis is inappropriate because pericarditis usually causes pleuritic pain and diffuse ST elevation with PR depression rather than focal inferior ST elevation with reciprocal changes."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hyperventilation syndrome does not produce localized ST-elevation changes with reciprocal depression."
            },
            {
              "id": "B",
              "text": "Option A: Acute pericarditis is inappropriate because pericarditis usually causes pleuritic pain and diffuse ST elevation with PR depression rather than focal inferior ST elevation with reciprocal changes."
            },
            {
              "id": "C",
              "text": "Option D: Pulmonary embolism may cause dyspnea and chest discomfort, but this ECG pattern is much more consistent with STEMI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hyperventilation syndrome does not produce localized ST-elevation changes with reciprocal depression."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary embolism may cause dyspnea and chest discomfort, but this ECG pattern is much more consistent with STEMI."
            },
            {
              "id": "B",
              "text": "Option A: Acute pericarditis is inappropriate because pericarditis usually causes pleuritic pain and diffuse ST elevation with PR depression rather than focal inferior ST elevation with reciprocal changes."
            },
            {
              "id": "C",
              "text": "Option B: Hyperventilation syndrome does not produce localized ST-elevation changes with reciprocal depression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary embolism may cause dyspnea and chest discomfort, but this ECG pattern is much more consistent with STEMI."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Spontaneous pneumothorax causes sudden dyspnea and pleuritic pain, usually with unilateral absent breath sounds, not this ECG pattern."
            },
            {
              "id": "B",
              "text": "Option A: Acute pericarditis is inappropriate because pericarditis usually causes pleuritic pain and diffuse ST elevation with PR depression rather than focal inferior ST elevation with reciprocal changes."
            },
            {
              "id": "C",
              "text": "Option B: Hyperventilation syndrome does not produce localized ST-elevation changes with reciprocal depression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Spontaneous pneumothorax causes sudden dyspnea and pleuritic pain, usually with unilateral absent breath sounds, not this ECG pattern."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute aortic dissection is inappropriate because aortic dissection can cause chest pain and shock, but the focal inferior STEMI pattern on ECG makes acute myocardial infarction most likely here."
            },
            {
              "id": "B",
              "text": "Option A: Acute pericarditis is inappropriate because pericarditis usually causes pleuritic pain and diffuse ST elevation with PR depression rather than focal inferior ST elevation with reciprocal changes."
            },
            {
              "id": "C",
              "text": "Option B: Hyperventilation syndrome does not produce localized ST-elevation changes with reciprocal depression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute aortic dissection is inappropriate because aortic dissection can cause chest pain and shock, but the focal inferior STEMI pattern on ECG makes acute myocardial infarction most likely here."
        }
      }
    },
    {
      "externalId": "free137-i022-poor-appetite-digoxin-toxicity",
      "expectedHashes": {
        "ranaze_step3_uat": "5ff5321e3f143afe9db2fc5a1a34c4713701be6c05048731a0246bd1423f3054",
        "ranaze_step3_prd": "5ff5321e3f143afe9db2fc5a1a34c4713701be6c05048731a0246bd1423f3054"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chest radiography can be useful for pulmonary symptoms or suspected thoracic disease, but it is not the most targeted first test here."
            },
            {
              "id": "B",
              "text": "Option B: A complete blood count can be reasonable in unexplained weight loss, but the medication-specific symptom pattern makes digoxin evaluation the priority."
            },
            {
              "id": "C",
              "text": "Option C: Serum albumin measurement is inappropriate because serum albumin is nonspecific and does not identify the likely cause of her new symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chest radiography can be useful for pulmonary symptoms or suspected thoracic disease, but it is not the most targeted first test here."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A complete blood count can be reasonable in unexplained weight loss, but the medication-specific symptom pattern makes digoxin evaluation the priority."
            },
            {
              "id": "B",
              "text": "Option A: Chest radiography can be useful for pulmonary symptoms or suspected thoracic disease, but it is not the most targeted first test here."
            },
            {
              "id": "C",
              "text": "Option C: Serum albumin measurement is inappropriate because serum albumin is nonspecific and does not identify the likely cause of her new symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A complete blood count can be reasonable in unexplained weight loss, but the medication-specific symptom pattern makes digoxin evaluation the priority."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum albumin measurement is inappropriate because serum albumin is nonspecific and does not identify the likely cause of her new symptoms."
            },
            {
              "id": "B",
              "text": "Option A: Chest radiography can be useful for pulmonary symptoms or suspected thoracic disease, but it is not the most targeted first test here."
            },
            {
              "id": "C",
              "text": "Option B: A complete blood count can be reasonable in unexplained weight loss, but the medication-specific symptom pattern makes digoxin evaluation the priority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum albumin measurement is inappropriate because serum albumin is nonspecific and does not identify the likely cause of her new symptoms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Upper endoscopy is not the best initial study without dysphagia, gastrointestinal bleeding, or focal abdominal symptoms."
            },
            {
              "id": "B",
              "text": "Option A: Chest radiography can be useful for pulmonary symptoms or suspected thoracic disease, but it is not the most targeted first test here."
            },
            {
              "id": "C",
              "text": "Option B: A complete blood count can be reasonable in unexplained weight loss, but the medication-specific symptom pattern makes digoxin evaluation the priority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Upper endoscopy is not the best initial study without dysphagia, gastrointestinal bleeding, or focal abdominal symptoms."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "TSH measurement is inappropriate because thyroid testing may be considered later, but it is less targeted than evaluating for digoxin toxicity first."
            },
            {
              "id": "B",
              "text": "Option A: Chest radiography can be useful for pulmonary symptoms or suspected thoracic disease, but it is not the most targeted first test here."
            },
            {
              "id": "C",
              "text": "Option B: A complete blood count can be reasonable in unexplained weight loss, but the medication-specific symptom pattern makes digoxin evaluation the priority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "TSH measurement is inappropriate because thyroid testing may be considered later, but it is less targeted than evaluating for digoxin toxicity first."
        }
      }
    },
    {
      "externalId": "free137-i025-limping-child-hip-ultrasound",
      "expectedHashes": {
        "ranaze_step3_uat": "324c69e0cf7ea62d6f20c0f2d08ceafb1f0d7f4ba4c76c0ce7ce81776114ce8f",
        "ranaze_step3_prd": "324c69e0cf7ea62d6f20c0f2d08ceafb1f0d7f4ba4c76c0ce7ce81776114ce8f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT scan of the pelvis is not the best next study when plain radiographs are already negative and the immediate question is whether a hip effusion is present."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the lumbar spine is not the best next test because the examination localizes the pain to the hip joint."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide bone scan is not the preferred next study for an acutely irritable hip when ultrasound can quickly assess for an effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT scan of the pelvis is not the best next study when plain radiographs are already negative and the immediate question is whether a hip effusion is present."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the lumbar spine is not the best next test because the examination localizes the pain to the hip joint."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is not the best next study when plain radiographs are already negative and the immediate question is whether a hip effusion is present."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide bone scan is not the preferred next study for an acutely irritable hip when ultrasound can quickly assess for an effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the lumbar spine is not the best next test because the examination localizes the pain to the hip joint."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radionuclide bone scan is not the preferred next study for an acutely irritable hip when ultrasound can quickly assess for an effusion."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is not the best next study when plain radiographs are already negative and the immediate question is whether a hip effusion is present."
            },
            {
              "id": "C",
              "text": "Option B: MRI of the lumbar spine is not the best next test because the examination localizes the pain to the hip joint."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radionuclide bone scan is not the preferred next study for an acutely irritable hip when ultrasound can quickly assess for an effusion."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contrast arthrography of the right hip is inappropriate because contrast arthrography is invasive and is not the next imaging study for initial evaluation of a child with a painful hip and normal plain films."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is not the best next study when plain radiographs are already negative and the immediate question is whether a hip effusion is present."
            },
            {
              "id": "C",
              "text": "Option B: MRI of the lumbar spine is not the best next test because the examination localizes the pain to the hip joint."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contrast arthrography of the right hip is inappropriate because contrast arthrography is invasive and is not the next imaging study for initial evaluation of a child with a painful hip and normal plain films."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat hip radiographs in 1 week is inappropriate because repeating radiographs later would delay evaluation of a child who now refuses to bear weight and still needs prompt assessment for hip effusion or infection."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is not the best next study when plain radiographs are already negative and the immediate question is whether a hip effusion is present."
            },
            {
              "id": "C",
              "text": "Option B: MRI of the lumbar spine is not the best next test because the examination localizes the pain to the hip joint."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat hip radiographs in 1 week is inappropriate because repeating radiographs later would delay evaluation of a child who now refuses to bear weight and still needs prompt assessment for hip effusion or infection."
        }
      }
    },
    {
      "externalId": "free137-i026-new-large-unilateral-pleural-effusion-thoracentesis",
      "expectedHashes": {
        "ranaze_step3_uat": "48958a99c290e55ceb2dd2938862c165c9466a68b92e5a264c47ef1367c75934",
        "ranaze_step3_prd": "48958a99c290e55ceb2dd2938862c165c9466a68b92e5a264c47ef1367c75934"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bone marrow biopsy is not an appropriate initial test for a new pleural effusion when the blood counts are not suggestive of marrow disease."
            },
            {
              "id": "B",
              "text": "Option B: Pericardiocentesis is used for pericardial effusion, not pleural effusion."
            },
            {
              "id": "C",
              "text": "Option C: Pleurodesis is a treatment for selected recurrent symptomatic pleural effusions after the cause is established, not the first diagnostic step."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bone marrow biopsy is not an appropriate initial test for a new pleural effusion when the blood counts are not suggestive of marrow disease."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pericardiocentesis is used for pericardial effusion, not pleural effusion."
            },
            {
              "id": "B",
              "text": "Option A: Bone marrow biopsy is not an appropriate initial test for a new pleural effusion when the blood counts are not suggestive of marrow disease."
            },
            {
              "id": "C",
              "text": "Option C: Pleurodesis is a treatment for selected recurrent symptomatic pleural effusions after the cause is established, not the first diagnostic step."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pericardiocentesis is used for pericardial effusion, not pleural effusion."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pleurodesis is a treatment for selected recurrent symptomatic pleural effusions after the cause is established, not the first diagnostic step."
            },
            {
              "id": "B",
              "text": "Option A: Bone marrow biopsy is not an appropriate initial test for a new pleural effusion when the blood counts are not suggestive of marrow disease."
            },
            {
              "id": "C",
              "text": "Option B: Pericardiocentesis is used for pericardial effusion, not pleural effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pleurodesis is a treatment for selected recurrent symptomatic pleural effusions after the cause is established, not the first diagnostic step."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Video-assisted thoracoscopic surgery may be considered later if needed, but initial evaluation of an unexplained pleural effusion starts with thoracentesis."
            },
            {
              "id": "B",
              "text": "Option A: Bone marrow biopsy is not an appropriate initial test for a new pleural effusion when the blood counts are not suggestive of marrow disease."
            },
            {
              "id": "C",
              "text": "Option B: Pericardiocentesis is used for pericardial effusion, not pleural effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Video-assisted thoracoscopic surgery may be considered later if needed, but initial evaluation of an unexplained pleural effusion starts with thoracentesis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Empiric intravenous diuresis only is inappropriate because empiric diuresis alone is insufficient because this is a large unilateral pleural effusion without obvious pulmonary edema and with no established cause."
            },
            {
              "id": "B",
              "text": "Option A: Bone marrow biopsy is not an appropriate initial test for a new pleural effusion when the blood counts are not suggestive of marrow disease."
            },
            {
              "id": "C",
              "text": "Option B: Pericardiocentesis is used for pericardial effusion, not pleural effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Empiric intravenous diuresis only is inappropriate because empiric diuresis alone is insufficient because this is a large unilateral pleural effusion without obvious pulmonary edema and with no established cause."
        }
      }
    },
    {
      "externalId": "free137-i027-preop-systemic-sclerosis-recognition",
      "expectedHashes": {
        "ranaze_step3_uat": "14cc29d4506c352d9c67c531d80f6040d36b8ba9faccb3f7993bec3bf10272ce",
        "ranaze_step3_prd": "14cc29d4506c352d9c67c531d80f6040d36b8ba9faccb3f7993bec3bf10272ce"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Masked facies and slowed movement can suggest Parkinson disease, but the skin tightening, limited oral aperture, color changes in the cold, and heartburn point instead to systemic sclerosis."
            },
            {
              "id": "B",
              "text": "Option B: Progressive supranuclear palsy does not explain the tight skin and cold-induced finger color changes."
            },
            {
              "id": "C",
              "text": "Option C: Sarcopenia causes loss of muscle mass and weakness, not tight skin and microstomia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Masked facies and slowed movement can suggest Parkinson disease, but the skin tightening, limited oral aperture, color changes in the cold, and heartburn point instead to systemic sclerosis."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Progressive supranuclear palsy does not explain the tight skin and cold-induced finger color changes."
            },
            {
              "id": "B",
              "text": "Option A: Masked facies and slowed movement can suggest Parkinson disease, but the skin tightening, limited oral aperture, color changes in the cold, and heartburn point instead to systemic sclerosis."
            },
            {
              "id": "C",
              "text": "Option C: Sarcopenia causes loss of muscle mass and weakness, not tight skin and microstomia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Progressive supranuclear palsy does not explain the tight skin and cold-induced finger color changes."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sarcopenia causes loss of muscle mass and weakness, not tight skin and microstomia."
            },
            {
              "id": "B",
              "text": "Option A: Masked facies and slowed movement can suggest Parkinson disease, but the skin tightening, limited oral aperture, color changes in the cold, and heartburn point instead to systemic sclerosis."
            },
            {
              "id": "C",
              "text": "Option B: Progressive supranuclear palsy does not explain the tight skin and cold-induced finger color changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sarcopenia causes loss of muscle mass and weakness, not tight skin and microstomia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Paget disease of bone does not explain the combination of tight skin, limited mouth opening, and Raynaud-type symptoms."
            },
            {
              "id": "B",
              "text": "Option A: Masked facies and slowed movement can suggest Parkinson disease, but the skin tightening, limited oral aperture, color changes in the cold, and heartburn point instead to systemic sclerosis."
            },
            {
              "id": "C",
              "text": "Option B: Progressive supranuclear palsy does not explain the tight skin and cold-induced finger color changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Paget disease of bone does not explain the combination of tight skin, limited mouth opening, and Raynaud-type symptoms."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Normal-pressure hydrocephalus does not explain the tight skin and limited mouth opening described here."
            },
            {
              "id": "B",
              "text": "Option A: Masked facies and slowed movement can suggest Parkinson disease, but the skin tightening, limited oral aperture, color changes in the cold, and heartburn point instead to systemic sclerosis."
            },
            {
              "id": "C",
              "text": "Option B: Progressive supranuclear palsy does not explain the tight skin and cold-induced finger color changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Normal-pressure hydrocephalus does not explain the tight skin and limited mouth opening described here."
        }
      }
    },
    {
      "externalId": "free137-i028-suspected-tuberculosis-mask-first",
      "expectedHashes": {
        "ranaze_step3_uat": "ef3315fd90db29b7690517ea6ee868b1aae6fbebd02ef534b73ea1968ecee997",
        "ranaze_step3_prd": "ef3315fd90db29b7690517ea6ee868b1aae6fbebd02ef534b73ea1968ecee997"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Send him directly to the emergency department without further evaluation is inappropriate because he is stable enough for immediate infection-control measures and continued evaluation rather than reflex transfer before precautions are taken."
            },
            {
              "id": "B",
              "text": "Option B: Finish the history and physical examination before taking precautions is inappropriate because completing the evaluation before precautions risks exposing staff and nearby patients if he has contagious pulmonary tuberculosis."
            },
            {
              "id": "C",
              "text": "Option D: Order a chest radiograph and examine other waiting patients while he is away is inappropriate because sending him for imaging before precautions risks avoidable exposure during transport and delays infection-control measures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Send him directly to the emergency department without further evaluation is inappropriate because he is stable enough for immediate infection-control measures and continued evaluation rather than reflex transfer before precautions are taken."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Finish the history and physical examination before taking precautions is inappropriate because completing the evaluation before precautions risks exposing staff and nearby patients if he has contagious pulmonary tuberculosis."
            },
            {
              "id": "B",
              "text": "Option A: Send him directly to the emergency department without further evaluation is inappropriate because he is stable enough for immediate infection-control measures and continued evaluation rather than reflex transfer before precautions are taken."
            },
            {
              "id": "C",
              "text": "Option D: Order a chest radiograph and examine other waiting patients while he is away is inappropriate because sending him for imaging before precautions risks avoidable exposure during transport and delays infection-control measures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Finish the history and physical examination before taking precautions is inappropriate because completing the evaluation before precautions risks exposing staff and nearby patients if he has contagious pulmonary tuberculosis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order a chest radiograph and examine other waiting patients while he is away is inappropriate because sending him for imaging before precautions risks avoidable exposure during transport and delays infection-control measures."
            },
            {
              "id": "B",
              "text": "Option A: Send him directly to the emergency department without further evaluation is inappropriate because he is stable enough for immediate infection-control measures and continued evaluation rather than reflex transfer before precautions are taken."
            },
            {
              "id": "C",
              "text": "Option B: Finish the history and physical examination before taking precautions is inappropriate because completing the evaluation before precautions risks exposing staff and nearby patients if he has contagious pulmonary tuberculosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order a chest radiograph and examine other waiting patients while he is away is inappropriate because sending him for imaging before precautions risks avoidable exposure during transport and delays infection-control measures."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask him to wait outside the clinic until a room becomes available is inappropriate because simply moving him outside is not the appropriate infection-control response; he still needs prompt masked evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Send him directly to the emergency department without further evaluation is inappropriate because he is stable enough for immediate infection-control measures and continued evaluation rather than reflex transfer before precautions are taken."
            },
            {
              "id": "C",
              "text": "Option B: Finish the history and physical examination before taking precautions is inappropriate because completing the evaluation before precautions risks exposing staff and nearby patients if he has contagious pulmonary tuberculosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask him to wait outside the clinic until a room becomes available is inappropriate because simply moving him outside is not the appropriate infection-control response; he still needs prompt masked evaluation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start empiric antibiotics for community-acquired pneumonia without isolation measures is inappropriate because empiric treatment without isolation measures is inappropriate when an airborne transmissible infection is plausible."
            },
            {
              "id": "B",
              "text": "Option A: Send him directly to the emergency department without further evaluation is inappropriate because he is stable enough for immediate infection-control measures and continued evaluation rather than reflex transfer before precautions are taken."
            },
            {
              "id": "C",
              "text": "Option B: Finish the history and physical examination before taking precautions is inappropriate because completing the evaluation before precautions risks exposing staff and nearby patients if he has contagious pulmonary tuberculosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start empiric antibiotics for community-acquired pneumonia without isolation measures is inappropriate because empiric treatment without isolation measures is inappropriate when an airborne transmissible infection is plausible."
        }
      }
    },
    {
      "externalId": "free137-i029-pid-pregnancy-test-first",
      "expectedHashes": {
        "ranaze_step3_uat": "8da798ff0d7daa573ed386c153d6365796e0b85e486f3bf78d84b9b17aad6cd7",
        "ranaze_step3_prd": "8da798ff0d7daa573ed386c153d6365796e0b85e486f3bf78d84b9b17aad6cd7"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Culdocentesis is rarely used in current practice and is not the preferred diagnostic study in a patient with classic PID findings."
            },
            {
              "id": "B",
              "text": "Option C: Diagnostic laparoscopy can be considered in selected uncertain cases, but PID is usually diagnosed clinically and initial STI testing should be obtained."
            },
            {
              "id": "C",
              "text": "Option D: Serum beta-hCG concentration is inappropriate because pregnancy testing is important in acute pelvic pain, but a urine pregnancy test has already been obtained and is negative."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Culdocentesis is rarely used in current practice and is not the preferred diagnostic study in a patient with classic PID findings."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diagnostic laparoscopy can be considered in selected uncertain cases, but PID is usually diagnosed clinically and initial STI testing should be obtained."
            },
            {
              "id": "B",
              "text": "Option B: Culdocentesis is rarely used in current practice and is not the preferred diagnostic study in a patient with classic PID findings."
            },
            {
              "id": "C",
              "text": "Option D: Serum beta-hCG concentration is inappropriate because pregnancy testing is important in acute pelvic pain, but a urine pregnancy test has already been obtained and is negative."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diagnostic laparoscopy can be considered in selected uncertain cases, but PID is usually diagnosed clinically and initial STI testing should be obtained."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum beta-hCG concentration is inappropriate because pregnancy testing is important in acute pelvic pain, but a urine pregnancy test has already been obtained and is negative."
            },
            {
              "id": "B",
              "text": "Option B: Culdocentesis is rarely used in current practice and is not the preferred diagnostic study in a patient with classic PID findings."
            },
            {
              "id": "C",
              "text": "Option C: Diagnostic laparoscopy can be considered in selected uncertain cases, but PID is usually diagnosed clinically and initial STI testing should be obtained."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum beta-hCG concentration is inappropriate because pregnancy testing is important in acute pelvic pain, but a urine pregnancy test has already been obtained and is negative."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pelvic ultrasonography can be useful if abscess, torsion, or another structural process is suspected, but it is not the key diagnostic study in this classic uncomplicated PID presentation."
            },
            {
              "id": "B",
              "text": "Option B: Culdocentesis is rarely used in current practice and is not the preferred diagnostic study in a patient with classic PID findings."
            },
            {
              "id": "C",
              "text": "Option C: Diagnostic laparoscopy can be considered in selected uncertain cases, but PID is usually diagnosed clinically and initial STI testing should be obtained."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pelvic ultrasonography can be useful if abscess, torsion, or another structural process is suspected, but it is not the key diagnostic study in this classic uncomplicated PID presentation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum CA-125 level is inappropriate because serum CA-125 is nonspecific and not part of the acute diagnostic evaluation of suspected PID."
            },
            {
              "id": "B",
              "text": "Option B: Culdocentesis is rarely used in current practice and is not the preferred diagnostic study in a patient with classic PID findings."
            },
            {
              "id": "C",
              "text": "Option C: Diagnostic laparoscopy can be considered in selected uncertain cases, but PID is usually diagnosed clinically and initial STI testing should be obtained."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum CA-125 level is inappropriate because serum CA-125 is nonspecific and not part of the acute diagnostic evaluation of suspected PID."
        }
      }
    },
    {
      "externalId": "free137-i030-poststrep-gn-low-c3",
      "expectedHashes": {
        "ranaze_step3_uat": "736f3b3e13bc6fdb1117557480baf5e322eee0e557d04f7caf40b2edf6af1434",
        "ranaze_step3_prd": "736f3b3e13bc6fdb1117557480baf5e322eee0e557d04f7caf40b2edf6af1434"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased serum IgA concentration is more consistent with IgA nephropathy, which classically causes hematuria during or within a day or two of a mucosal infection rather than after a latent interval."
            },
            {
              "id": "B",
              "text": "Option C: Prolonged bleeding time suggests a platelet disorder, not a postinfectious nephritic syndrome."
            },
            {
              "id": "C",
              "text": "Option D: Positive rheumatoid factor assay is inappropriate because rheumatoid factor is not a characteristic laboratory abnormality in poststreptococcal glomerulonephritis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased serum IgA concentration is more consistent with IgA nephropathy, which classically causes hematuria during or within a day or two of a mucosal infection rather than after a latent interval."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prolonged bleeding time suggests a platelet disorder, not a postinfectious nephritic syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Increased serum IgA concentration is more consistent with IgA nephropathy, which classically causes hematuria during or within a day or two of a mucosal infection rather than after a latent interval."
            },
            {
              "id": "C",
              "text": "Option D: Positive rheumatoid factor assay is inappropriate because rheumatoid factor is not a characteristic laboratory abnormality in poststreptococcal glomerulonephritis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prolonged bleeding time suggests a platelet disorder, not a postinfectious nephritic syndrome."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Positive rheumatoid factor assay is inappropriate because rheumatoid factor is not a characteristic laboratory abnormality in poststreptococcal glomerulonephritis."
            },
            {
              "id": "B",
              "text": "Option B: Increased serum IgA concentration is more consistent with IgA nephropathy, which classically causes hematuria during or within a day or two of a mucosal infection rather than after a latent interval."
            },
            {
              "id": "C",
              "text": "Option C: Prolonged bleeding time suggests a platelet disorder, not a postinfectious nephritic syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Positive rheumatoid factor assay is inappropriate because rheumatoid factor is not a characteristic laboratory abnormality in poststreptococcal glomerulonephritis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A positive antinuclear antibody test suggests an autoimmune process such as lupus, not the classic postpharyngitic nephritic syndrome shown here."
            },
            {
              "id": "B",
              "text": "Option B: Increased serum IgA concentration is more consistent with IgA nephropathy, which classically causes hematuria during or within a day or two of a mucosal infection rather than after a latent interval."
            },
            {
              "id": "C",
              "text": "Option C: Prolonged bleeding time suggests a platelet disorder, not a postinfectious nephritic syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A positive antinuclear antibody test suggests an autoimmune process such as lupus, not the classic postpharyngitic nephritic syndrome shown here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low serum ceruloplasmin level is inappropriate because low ceruloplasmin is associated with Wilson disease and is unrelated to this presentation."
            },
            {
              "id": "B",
              "text": "Option B: Increased serum IgA concentration is more consistent with IgA nephropathy, which classically causes hematuria during or within a day or two of a mucosal infection rather than after a latent interval."
            },
            {
              "id": "C",
              "text": "Option C: Prolonged bleeding time suggests a platelet disorder, not a postinfectious nephritic syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low serum ceruloplasmin level is inappropriate because low ceruloplasmin is associated with Wilson disease and is unrelated to this presentation."
        }
      }
    },
    {
      "externalId": "free137-i031-somatic-symptom-disorder",
      "expectedHashes": {
        "ranaze_step3_uat": "574fc3be9769932b81ec7998a2e4ba1cabd445e8aa701d5ab8b8d72715fc7c1b",
        "ranaze_step3_prd": "574fc3be9769932b81ec7998a2e4ba1cabd445e8aa701d5ab8b8d72715fc7c1b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Illness anxiety disorder is characterized by fear of serious illness with minimal or absent somatic symptoms, which does not fit this long history of multiple prominent symptoms."
            },
            {
              "id": "B",
              "text": "Option C: Conversion disorder causes functional neurologic symptoms, not a decades-long pattern of recurrent pain complaints across multiple body systems."
            },
            {
              "id": "C",
              "text": "Option D: Borderline personality disorder involves pervasive instability of relationships, self-image, and affect, which is not the central pattern described here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Illness anxiety disorder is characterized by fear of serious illness with minimal or absent somatic symptoms, which does not fit this long history of multiple prominent symptoms."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Conversion disorder causes functional neurologic symptoms, not a decades-long pattern of recurrent pain complaints across multiple body systems."
            },
            {
              "id": "B",
              "text": "Option B: Illness anxiety disorder is characterized by fear of serious illness with minimal or absent somatic symptoms, which does not fit this long history of multiple prominent symptoms."
            },
            {
              "id": "C",
              "text": "Option D: Borderline personality disorder involves pervasive instability of relationships, self-image, and affect, which is not the central pattern described here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Conversion disorder causes functional neurologic symptoms, not a decades-long pattern of recurrent pain complaints across multiple body systems."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Borderline personality disorder involves pervasive instability of relationships, self-image, and affect, which is not the central pattern described here."
            },
            {
              "id": "B",
              "text": "Option B: Illness anxiety disorder is characterized by fear of serious illness with minimal or absent somatic symptoms, which does not fit this long history of multiple prominent symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Conversion disorder causes functional neurologic symptoms, not a decades-long pattern of recurrent pain complaints across multiple body systems."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Borderline personality disorder involves pervasive instability of relationships, self-image, and affect, which is not the central pattern described here."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Histrionic personality disorder may involve attention-seeking behavior, but it does not best explain the dominant pattern of repeated medical care for multiple distressing physical symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Illness anxiety disorder is characterized by fear of serious illness with minimal or absent somatic symptoms, which does not fit this long history of multiple prominent symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Conversion disorder causes functional neurologic symptoms, not a decades-long pattern of recurrent pain complaints across multiple body systems."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Histrionic personality disorder may involve attention-seeking behavior, but it does not best explain the dominant pattern of repeated medical care for multiple distressing physical symptoms."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Malingering requires intentional symptom production for an external incentive, and the stem gives no such incentive."
            },
            {
              "id": "B",
              "text": "Option B: Illness anxiety disorder is characterized by fear of serious illness with minimal or absent somatic symptoms, which does not fit this long history of multiple prominent symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Conversion disorder causes functional neurologic symptoms, not a decades-long pattern of recurrent pain complaints across multiple body systems."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Malingering requires intentional symptom production for an external incentive, and the stem gives no such incentive."
        }
      }
    },
    {
      "externalId": "free137-i032-case-control-ascertainment-bias",
      "expectedHashes": {
        "ranaze_step3_uat": "b089d604d14599b11b2cf577576215593c4a825348e78652eb6631d8eedad536",
        "ranaze_step3_prd": "b089d604d14599b11b2cf577576215593c4a825348e78652eb6631d8eedad536"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "To reduce confounding by smoking is inappropriate because balancing imaging does not control for smoking as a confounder."
            },
            {
              "id": "B",
              "text": "Option B: To establish causality is inappropriate because a case-control study can identify associations, but it does not establish causality simply by standardizing imaging opportunity."
            },
            {
              "id": "C",
              "text": "Option D: To reduce recall bias is inappropriate because recall bias involves differences in remembered exposures; here the imaging history is taken from an insurer database."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "To reduce confounding by smoking is inappropriate because balancing imaging does not control for smoking as a confounder."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "To establish causality is inappropriate because a case-control study can identify associations, but it does not establish causality simply by standardizing imaging opportunity."
            },
            {
              "id": "B",
              "text": "Option A: To reduce confounding by smoking is inappropriate because balancing imaging does not control for smoking as a confounder."
            },
            {
              "id": "C",
              "text": "Option D: To reduce recall bias is inappropriate because recall bias involves differences in remembered exposures; here the imaging history is taken from an insurer database."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "To establish causality is inappropriate because a case-control study can identify associations, but it does not establish causality simply by standardizing imaging opportunity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "To reduce recall bias is inappropriate because recall bias involves differences in remembered exposures; here the imaging history is taken from an insurer database."
            },
            {
              "id": "B",
              "text": "Option A: To reduce confounding by smoking is inappropriate because balancing imaging does not control for smoking as a confounder."
            },
            {
              "id": "C",
              "text": "Option B: To establish causality is inappropriate because a case-control study can identify associations, but it does not establish causality simply by standardizing imaging opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "To reduce recall bias is inappropriate because recall bias involves differences in remembered exposures; here the imaging history is taken from an insurer database."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "To improve precision by increasing sample size is inappropriate because restricting eligibility to workers with chest CT scans would usually reduce, not increase, sample size."
            },
            {
              "id": "B",
              "text": "Option A: To reduce confounding by smoking is inappropriate because balancing imaging does not control for smoking as a confounder."
            },
            {
              "id": "C",
              "text": "Option B: To establish causality is inappropriate because a case-control study can identify associations, but it does not establish causality simply by standardizing imaging opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "To improve precision by increasing sample size is inappropriate because restricting eligibility to workers with chest CT scans would usually reduce, not increase, sample size."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "To eliminate selection bias is inappropriate because this step addresses differential outcome detection, not every possible source of selection bias."
            },
            {
              "id": "B",
              "text": "Option A: To reduce confounding by smoking is inappropriate because balancing imaging does not control for smoking as a confounder."
            },
            {
              "id": "C",
              "text": "Option B: To establish causality is inappropriate because a case-control study can identify associations, but it does not establish causality simply by standardizing imaging opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "To eliminate selection bias is inappropriate because this step addresses differential outcome detection, not every possible source of selection bias."
        }
      }
    },
    {
      "externalId": "free137-i035-relative-risk-calculation",
      "expectedHashes": {
        "ranaze_step3_uat": "7407bc0f5ded2d937fa5a1509d8181fbb77ca76818c70444258f13ef93834e43",
        "ranaze_step3_prd": "7407bc0f5ded2d937fa5a1509d8181fbb77ca76818c70444258f13ef93834e43"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "0.5 is inappropriate because this is too low; the exposed group has a higher event proportion than the unexposed group."
            },
            {
              "id": "B",
              "text": "Option B: 1.0 is inappropriate because this would mean the 2 groups had the same risk, but the event proportions are different."
            },
            {
              "id": "C",
              "text": "Option C: 1.5 is inappropriate because this does not use the stated denominators correctly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "0.5 is inappropriate because this is too low; the exposed group has a higher event proportion than the unexposed group."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "1.0 is inappropriate because this would mean the 2 groups had the same risk, but the event proportions are different."
            },
            {
              "id": "B",
              "text": "Option A: 0.5 is inappropriate because this is too low; the exposed group has a higher event proportion than the unexposed group."
            },
            {
              "id": "C",
              "text": "Option C: 1.5 is inappropriate because this does not use the stated denominators correctly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "1.0 is inappropriate because this would mean the 2 groups had the same risk, but the event proportions are different."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "1.5 is inappropriate because this does not use the stated denominators correctly."
            },
            {
              "id": "B",
              "text": "Option A: 0.5 is inappropriate because this is too low; the exposed group has a higher event proportion than the unexposed group."
            },
            {
              "id": "C",
              "text": "Option B: 1.0 is inappropriate because this would mean the 2 groups had the same risk, but the event proportions are different."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "1.5 is inappropriate because this does not use the stated denominators correctly."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "3.0 is inappropriate because this overstates the ratio obtained from the stated event counts and denominators."
            },
            {
              "id": "B",
              "text": "Option A: 0.5 is inappropriate because this is too low; the exposed group has a higher event proportion than the unexposed group."
            },
            {
              "id": "C",
              "text": "Option B: 1.0 is inappropriate because this would mean the 2 groups had the same risk, but the event proportions are different."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "3.0 is inappropriate because this overstates the ratio obtained from the stated event counts and denominators."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Relative risk cannot be calculated from these data is inappropriate because relative risk can be calculated because the stem gives the outcome counts and total group sizes for both exposed and unexposed patients."
            },
            {
              "id": "B",
              "text": "Option A: 0.5 is inappropriate because this is too low; the exposed group has a higher event proportion than the unexposed group."
            },
            {
              "id": "C",
              "text": "Option B: 1.0 is inappropriate because this would mean the 2 groups had the same risk, but the event proportions are different."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Relative risk cannot be calculated from these data is inappropriate because relative risk can be calculated because the stem gives the outcome counts and total group sizes for both exposed and unexposed patients."
        }
      }
    },
    {
      "externalId": "free137-i038-lumbar-disc-s1-radiculopathy",
      "expectedHashes": {
        "ranaze_step3_uat": "e6e99d6d9bc62d64da07a599d74710117ee193dfa3365feadc4d6d4f60e5e812",
        "ranaze_step3_prd": "e6e99d6d9bc62d64da07a599d74710117ee193dfa3365feadc4d6d4f60e5e812"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Degenerative hypertrophy of the facet joints causing central canal stenosis is inappropriate because facet hypertrophy more often contributes to chronic lumbar spinal stenosis rather than abrupt unilateral radiculopathy after lifting."
            },
            {
              "id": "B",
              "text": "Option C: Osteophyte-related foraminal narrowing from lumbar spondylosis is inappropriate because osteophyte-related narrowing from spondylosis usually produces a more gradual degenerative presentation."
            },
            {
              "id": "C",
              "text": "Option D: Anterior slippage of L5 on S1 is inappropriate because spondylolisthesis can cause back pain and radiculopathy, but the classic acute post-lifting radicular syndrome here most strongly supports disc herniation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Degenerative hypertrophy of the facet joints causing central canal stenosis is inappropriate because facet hypertrophy more often contributes to chronic lumbar spinal stenosis rather than abrupt unilateral radiculopathy after lifting."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Osteophyte-related foraminal narrowing from lumbar spondylosis is inappropriate because osteophyte-related narrowing from spondylosis usually produces a more gradual degenerative presentation."
            },
            {
              "id": "B",
              "text": "Option B: Degenerative hypertrophy of the facet joints causing central canal stenosis is inappropriate because facet hypertrophy more often contributes to chronic lumbar spinal stenosis rather than abrupt unilateral radiculopathy after lifting."
            },
            {
              "id": "C",
              "text": "Option D: Anterior slippage of L5 on S1 is inappropriate because spondylolisthesis can cause back pain and radiculopathy, but the classic acute post-lifting radicular syndrome here most strongly supports disc herniation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Osteophyte-related foraminal narrowing from lumbar spondylosis is inappropriate because osteophyte-related narrowing from spondylosis usually produces a more gradual degenerative presentation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anterior slippage of L5 on S1 is inappropriate because spondylolisthesis can cause back pain and radiculopathy, but the classic acute post-lifting radicular syndrome here most strongly supports disc herniation."
            },
            {
              "id": "B",
              "text": "Option B: Degenerative hypertrophy of the facet joints causing central canal stenosis is inappropriate because facet hypertrophy more often contributes to chronic lumbar spinal stenosis rather than abrupt unilateral radiculopathy after lifting."
            },
            {
              "id": "C",
              "text": "Option C: Osteophyte-related foraminal narrowing from lumbar spondylosis is inappropriate because osteophyte-related narrowing from spondylosis usually produces a more gradual degenerative presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anterior slippage of L5 on S1 is inappropriate because spondylolisthesis can cause back pain and radiculopathy, but the classic acute post-lifting radicular syndrome here most strongly supports disc herniation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thickening of the ligamentum flavum is inappropriate because ligamentum flavum thickening is another chronic degenerative contributor to lumbar stenosis rather than an abrupt single-root syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Degenerative hypertrophy of the facet joints causing central canal stenosis is inappropriate because facet hypertrophy more often contributes to chronic lumbar spinal stenosis rather than abrupt unilateral radiculopathy after lifting."
            },
            {
              "id": "C",
              "text": "Option C: Osteophyte-related foraminal narrowing from lumbar spondylosis is inappropriate because osteophyte-related narrowing from spondylosis usually produces a more gradual degenerative presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thickening of the ligamentum flavum is inappropriate because ligamentum flavum thickening is another chronic degenerative contributor to lumbar stenosis rather than an abrupt single-root syndrome."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inflammation of the sacroiliac joint is inappropriate because sacroiliac inflammation causes buttock or posterior pelvic pain, not objective S1 neurologic deficits."
            },
            {
              "id": "B",
              "text": "Option B: Degenerative hypertrophy of the facet joints causing central canal stenosis is inappropriate because facet hypertrophy more often contributes to chronic lumbar spinal stenosis rather than abrupt unilateral radiculopathy after lifting."
            },
            {
              "id": "C",
              "text": "Option C: Osteophyte-related foraminal narrowing from lumbar spondylosis is inappropriate because osteophyte-related narrowing from spondylosis usually produces a more gradual degenerative presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inflammation of the sacroiliac joint is inappropriate because sacroiliac inflammation causes buttock or posterior pelvic pain, not objective S1 neurologic deficits."
        }
      }
    },
    {
      "externalId": "free137-i039-pancreatitis-hypocalcemia-poor-prognosis",
      "expectedHashes": {
        "ranaze_step3_uat": "4aee6abf5d8ff6b6719ed01004aee86e3365a024e7e6ca791afc8da0552b4aa6",
        "ranaze_step3_prd": "4aee6abf5d8ff6b6719ed01004aee86e3365a024e7e6ca791afc8da0552b4aa6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alanine aminotransferase 118 U/L is inappropriate because aLT elevation can help suggest biliary disease, but it is not the strongest 48-hour poor-prognosis marker here."
            },
            {
              "id": "B",
              "text": "Option B: Lipase 2200 U/L is inappropriate because pancreatic enzyme magnitude does not reliably correlate with severity after the diagnosis of pancreatitis is established."
            },
            {
              "id": "C",
              "text": "Option C: Total bilirubin 3.8 mg/dL is inappropriate because hyperbilirubinemia may suggest biliary obstruction, but it is not the best 48-hour severity marker among these options."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alanine aminotransferase 118 U/L is inappropriate because aLT elevation can help suggest biliary disease, but it is not the strongest 48-hour poor-prognosis marker here."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lipase 2200 U/L is inappropriate because pancreatic enzyme magnitude does not reliably correlate with severity after the diagnosis of pancreatitis is established."
            },
            {
              "id": "B",
              "text": "Option A: Alanine aminotransferase 118 U/L is inappropriate because aLT elevation can help suggest biliary disease, but it is not the strongest 48-hour poor-prognosis marker here."
            },
            {
              "id": "C",
              "text": "Option C: Total bilirubin 3.8 mg/dL is inappropriate because hyperbilirubinemia may suggest biliary obstruction, but it is not the best 48-hour severity marker among these options."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lipase 2200 U/L is inappropriate because pancreatic enzyme magnitude does not reliably correlate with severity after the diagnosis of pancreatitis is established."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Total bilirubin 3.8 mg/dL is inappropriate because hyperbilirubinemia may suggest biliary obstruction, but it is not the best 48-hour severity marker among these options."
            },
            {
              "id": "B",
              "text": "Option A: Alanine aminotransferase 118 U/L is inappropriate because aLT elevation can help suggest biliary disease, but it is not the strongest 48-hour poor-prognosis marker here."
            },
            {
              "id": "C",
              "text": "Option B: Lipase 2200 U/L is inappropriate because pancreatic enzyme magnitude does not reliably correlate with severity after the diagnosis of pancreatitis is established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Total bilirubin 3.8 mg/dL is inappropriate because hyperbilirubinemia may suggest biliary obstruction, but it is not the best 48-hour severity marker among these options."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Glucose 208 mg/dL is inappropriate because hyperglycemia can occur in pancreatitis, but severe hypocalcemia is the more concerning classic severity marker in this setting."
            },
            {
              "id": "B",
              "text": "Option A: Alanine aminotransferase 118 U/L is inappropriate because aLT elevation can help suggest biliary disease, but it is not the strongest 48-hour poor-prognosis marker here."
            },
            {
              "id": "C",
              "text": "Option B: Lipase 2200 U/L is inappropriate because pancreatic enzyme magnitude does not reliably correlate with severity after the diagnosis of pancreatitis is established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Glucose 208 mg/dL is inappropriate because hyperglycemia can occur in pancreatitis, but severe hypocalcemia is the more concerning classic severity marker in this setting."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Triglycerides 260 mg/dL is inappropriate because a triglyceride level of 260 mg/dL is nonspecific and does not by itself indicate severe short-term progression."
            },
            {
              "id": "B",
              "text": "Option A: Alanine aminotransferase 118 U/L is inappropriate because aLT elevation can help suggest biliary disease, but it is not the strongest 48-hour poor-prognosis marker here."
            },
            {
              "id": "C",
              "text": "Option B: Lipase 2200 U/L is inappropriate because pancreatic enzyme magnitude does not reliably correlate with severity after the diagnosis of pancreatitis is established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Triglycerides 260 mg/dL is inappropriate because a triglyceride level of 260 mg/dL is nonspecific and does not by itself indicate severe short-term progression."
        }
      }
    },
    {
      "externalId": "free137-i040-acalculous-cholecystitis-initial-ultrasound",
      "expectedHashes": {
        "ranaze_step3_uat": "ea0d9d61bdcaa34f942d4a6f579e8966e2ba4d0d9ad1ac99c62eb75568f0cf16",
        "ranaze_step3_prd": "ea0d9d61bdcaa34f942d4a6f579e8966e2ba4d0d9ad1ac99c62eb75568f0cf16"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hepatobiliary scintigraphy can clarify equivocal ultrasonography but is not the first study."
            },
            {
              "id": "B",
              "text": "Option C: CT angiography of the abdomen is inappropriate because cT angiography is not the initial test for this focal biliary presentation without hemorrhage or ischemia."
            },
            {
              "id": "C",
              "text": "Option D: Endoscopic retrograde cholangiopancreatography is inappropriate because eRCP is therapeutic for ductal obstruction or cholangitis, neither of which is established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hepatobiliary scintigraphy can clarify equivocal ultrasonography but is not the first study."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT angiography of the abdomen is inappropriate because cT angiography is not the initial test for this focal biliary presentation without hemorrhage or ischemia."
            },
            {
              "id": "B",
              "text": "Option B: Hepatobiliary scintigraphy can clarify equivocal ultrasonography but is not the first study."
            },
            {
              "id": "C",
              "text": "Option D: Endoscopic retrograde cholangiopancreatography is inappropriate because eRCP is therapeutic for ductal obstruction or cholangitis, neither of which is established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT angiography of the abdomen is inappropriate because cT angiography is not the initial test for this focal biliary presentation without hemorrhage or ischemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Endoscopic retrograde cholangiopancreatography is inappropriate because eRCP is therapeutic for ductal obstruction or cholangitis, neither of which is established."
            },
            {
              "id": "B",
              "text": "Option B: Hepatobiliary scintigraphy can clarify equivocal ultrasonography but is not the first study."
            },
            {
              "id": "C",
              "text": "Option C: CT angiography of the abdomen is inappropriate because cT angiography is not the initial test for this focal biliary presentation without hemorrhage or ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Endoscopic retrograde cholangiopancreatography is inappropriate because eRCP is therapeutic for ductal obstruction or cholangitis, neither of which is established."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Upper endoscopy does not evaluate the gallbladder."
            },
            {
              "id": "B",
              "text": "Option B: Hepatobiliary scintigraphy can clarify equivocal ultrasonography but is not the first study."
            },
            {
              "id": "C",
              "text": "Option C: CT angiography of the abdomen is inappropriate because cT angiography is not the initial test for this focal biliary presentation without hemorrhage or ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Upper endoscopy does not evaluate the gallbladder."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diagnostic laparoscopy is inappropriate because surgical exploration should follow diagnostic imaging unless perforation or peritonitis is present."
            },
            {
              "id": "B",
              "text": "Option B: Hepatobiliary scintigraphy can clarify equivocal ultrasonography but is not the first study."
            },
            {
              "id": "C",
              "text": "Option C: CT angiography of the abdomen is inappropriate because cT angiography is not the initial test for this focal biliary presentation without hemorrhage or ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diagnostic laparoscopy is inappropriate because surgical exploration should follow diagnostic imaging unless perforation or peritonitis is present."
        }
      }
    },
    {
      "externalId": "free137-i043-child-positive-tst-next-step",
      "expectedHashes": {
        "ranaze_step3_uat": "8aa8df4c211cad15d70a820dfe10bdbe37b88199f64160f8b409c4b594323ea6",
        "ranaze_step3_prd": "8aa8df4c211cad15d70a820dfe10bdbe37b88199f64160f8b409c4b594323ea6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain outside records before any further evaluation is inappropriate because prior records may be useful later, but a newly positive screening test should be evaluated now rather than delayed for record collection."
            },
            {
              "id": "B",
              "text": "Option C: Order HIV antibody testing before additional tuberculosis evaluation is inappropriate because hIV testing may be considered in some patients, but it is not the immediate next step after a positive screening TB test."
            },
            {
              "id": "C",
              "text": "Option D: Repeat the tuberculin skin test in 1 week is inappropriate because repeating the skin test is unnecessary because this result is already positive in this clinical context."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain outside records before any further evaluation is inappropriate because prior records may be useful later, but a newly positive screening test should be evaluated now rather than delayed for record collection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order HIV antibody testing before additional tuberculosis evaluation is inappropriate because hIV testing may be considered in some patients, but it is not the immediate next step after a positive screening TB test."
            },
            {
              "id": "B",
              "text": "Option A: Obtain outside records before any further evaluation is inappropriate because prior records may be useful later, but a newly positive screening test should be evaluated now rather than delayed for record collection."
            },
            {
              "id": "C",
              "text": "Option D: Repeat the tuberculin skin test in 1 week is inappropriate because repeating the skin test is unnecessary because this result is already positive in this clinical context."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order HIV antibody testing before additional tuberculosis evaluation is inappropriate because hIV testing may be considered in some patients, but it is not the immediate next step after a positive screening TB test."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat the tuberculin skin test in 1 week is inappropriate because repeating the skin test is unnecessary because this result is already positive in this clinical context."
            },
            {
              "id": "B",
              "text": "Option A: Obtain outside records before any further evaluation is inappropriate because prior records may be useful later, but a newly positive screening test should be evaluated now rather than delayed for record collection."
            },
            {
              "id": "C",
              "text": "Option C: Order HIV antibody testing before additional tuberculosis evaluation is inappropriate because hIV testing may be considered in some patients, but it is not the immediate next step after a positive screening TB test."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat the tuberculin skin test in 1 week is inappropriate because repeating the skin test is unnecessary because this result is already positive in this clinical context."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange serial gastric aspirates for mycobacterial culture now is inappropriate because gastric aspirates are not the first step in an otherwise stable child with a newly positive screening test before chest imaging."
            },
            {
              "id": "B",
              "text": "Option A: Obtain outside records before any further evaluation is inappropriate because prior records may be useful later, but a newly positive screening test should be evaluated now rather than delayed for record collection."
            },
            {
              "id": "C",
              "text": "Option C: Order HIV antibody testing before additional tuberculosis evaluation is inappropriate because hIV testing may be considered in some patients, but it is not the immediate next step after a positive screening TB test."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange serial gastric aspirates for mycobacterial culture now is inappropriate because gastric aspirates are not the first step in an otherwise stable child with a newly positive screening test before chest imaging."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start empiric 4-drug antituberculous therapy immediately is inappropriate because immediate multidrug treatment is not the next step in an asymptomatic child before evaluation for active disease."
            },
            {
              "id": "B",
              "text": "Option A: Obtain outside records before any further evaluation is inappropriate because prior records may be useful later, but a newly positive screening test should be evaluated now rather than delayed for record collection."
            },
            {
              "id": "C",
              "text": "Option C: Order HIV antibody testing before additional tuberculosis evaluation is inappropriate because hIV testing may be considered in some patients, but it is not the immediate next step after a positive screening TB test."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start empiric 4-drug antituberculous therapy immediately is inappropriate because immediate multidrug treatment is not the next step in an asymptomatic child before evaluation for active disease."
        }
      }
    },
    {
      "externalId": "free137-i044-methanol-toxic-alcohol",
      "expectedHashes": {
        "ranaze_step3_uat": "d2fbcb684a37e821148de721f1d9f26a47782caf5a7051a725973be58f71a56f",
        "ranaze_step3_prd": "d2fbcb684a37e821148de721f1d9f26a47782caf5a7051a725973be58f71a56f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alcoholic ketoacidosis can cause an anion gap acidosis, but it does not typically cause optic disc hyperemia and retinal edema."
            },
            {
              "id": "B",
              "text": "Option B: Diabetic ketoacidosis usually causes marked hyperglycemia, which is not present here."
            },
            {
              "id": "C",
              "text": "Option C: Isopropyl alcohol intoxication classically causes ketosis without a severe metabolic acidosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alcoholic ketoacidosis can cause an anion gap acidosis, but it does not typically cause optic disc hyperemia and retinal edema."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diabetic ketoacidosis usually causes marked hyperglycemia, which is not present here."
            },
            {
              "id": "B",
              "text": "Option A: Alcoholic ketoacidosis can cause an anion gap acidosis, but it does not typically cause optic disc hyperemia and retinal edema."
            },
            {
              "id": "C",
              "text": "Option C: Isopropyl alcohol intoxication classically causes ketosis without a severe metabolic acidosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diabetic ketoacidosis usually causes marked hyperglycemia, which is not present here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isopropyl alcohol intoxication classically causes ketosis without a severe metabolic acidosis."
            },
            {
              "id": "B",
              "text": "Option A: Alcoholic ketoacidosis can cause an anion gap acidosis, but it does not typically cause optic disc hyperemia and retinal edema."
            },
            {
              "id": "C",
              "text": "Option B: Diabetic ketoacidosis usually causes marked hyperglycemia, which is not present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isopropyl alcohol intoxication classically causes ketosis without a severe metabolic acidosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Salicylate intoxication can cause acid-base abnormalities, but the ocular findings and toxic alcohol exposure pattern are more consistent with methanol."
            },
            {
              "id": "B",
              "text": "Option A: Alcoholic ketoacidosis can cause an anion gap acidosis, but it does not typically cause optic disc hyperemia and retinal edema."
            },
            {
              "id": "C",
              "text": "Option B: Diabetic ketoacidosis usually causes marked hyperglycemia, which is not present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Salicylate intoxication can cause acid-base abnormalities, but the ocular findings and toxic alcohol exposure pattern are more consistent with methanol."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ethylene glycol intoxication is inappropriate because ethylene glycol can also cause toxic alcohol acidosis, but visual toxicity points more strongly to methanol, and this urinalysis shows no crystals."
            },
            {
              "id": "B",
              "text": "Option A: Alcoholic ketoacidosis can cause an anion gap acidosis, but it does not typically cause optic disc hyperemia and retinal edema."
            },
            {
              "id": "C",
              "text": "Option B: Diabetic ketoacidosis usually causes marked hyperglycemia, which is not present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ethylene glycol intoxication is inappropriate because ethylene glycol can also cause toxic alcohol acidosis, but visual toxicity points more strongly to methanol, and this urinalysis shows no crystals."
        }
      }
    },
    {
      "externalId": "free137-i045-pneumonia-refractory-hypoxemia-shunt",
      "expectedHashes": {
        "ranaze_step3_uat": "1a35997a2d25f89e6d0acfd5bbc7bf4437c52c4074127e0bbddce9f0a4e0f596",
        "ranaze_step3_prd": "1a35997a2d25f89e6d0acfd5bbc7bf4437c52c4074127e0bbddce9f0a4e0f596"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diffusion limitation alone is inappropriate because diffusion limitation usually improves substantially with supplemental oxygen."
            },
            {
              "id": "B",
              "text": "Option B: Low inspired oxygen tension is inappropriate because the inspired oxygen concentration is 100%, so low inspired oxygen is excluded."
            },
            {
              "id": "C",
              "text": "Option D: Reduced mixed venous oxygen content alone is inappropriate because low mixed venous oxygen can worsen hypoxemia but does not explain failure to respond to FIO2 1.0 with dense consolidation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diffusion limitation alone is inappropriate because diffusion limitation usually improves substantially with supplemental oxygen."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low inspired oxygen tension is inappropriate because the inspired oxygen concentration is 100%, so low inspired oxygen is excluded."
            },
            {
              "id": "B",
              "text": "Option A: Diffusion limitation alone is inappropriate because diffusion limitation usually improves substantially with supplemental oxygen."
            },
            {
              "id": "C",
              "text": "Option D: Reduced mixed venous oxygen content alone is inappropriate because low mixed venous oxygen can worsen hypoxemia but does not explain failure to respond to FIO2 1.0 with dense consolidation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low inspired oxygen tension is inappropriate because the inspired oxygen concentration is 100%, so low inspired oxygen is excluded."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduced mixed venous oxygen content alone is inappropriate because low mixed venous oxygen can worsen hypoxemia but does not explain failure to respond to FIO2 1.0 with dense consolidation."
            },
            {
              "id": "B",
              "text": "Option A: Diffusion limitation alone is inappropriate because diffusion limitation usually improves substantially with supplemental oxygen."
            },
            {
              "id": "C",
              "text": "Option B: Low inspired oxygen tension is inappropriate because the inspired oxygen concentration is 100%, so low inspired oxygen is excluded."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduced mixed venous oxygen content alone is inappropriate because low mixed venous oxygen can worsen hypoxemia but does not explain failure to respond to FIO2 1.0 with dense consolidation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alveolar hyperventilation is inappropriate because hyperventilation lowers carbon dioxide and does not cause this refractory hypoxemia."
            },
            {
              "id": "B",
              "text": "Option A: Diffusion limitation alone is inappropriate because diffusion limitation usually improves substantially with supplemental oxygen."
            },
            {
              "id": "C",
              "text": "Option B: Low inspired oxygen tension is inappropriate because the inspired oxygen concentration is 100%, so low inspired oxygen is excluded."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alveolar hyperventilation is inappropriate because hyperventilation lowers carbon dioxide and does not cause this refractory hypoxemia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased physiologic dead space alone is inappropriate because dead-space ventilation causes inefficient carbon dioxide elimination rather than profound oxygen-refractory hypoxemia."
            },
            {
              "id": "B",
              "text": "Option A: Diffusion limitation alone is inappropriate because diffusion limitation usually improves substantially with supplemental oxygen."
            },
            {
              "id": "C",
              "text": "Option B: Low inspired oxygen tension is inappropriate because the inspired oxygen concentration is 100%, so low inspired oxygen is excluded."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased physiologic dead space alone is inappropriate because dead-space ventilation causes inefficient carbon dioxide elimination rather than profound oxygen-refractory hypoxemia."
        }
      }
    },
    {
      "externalId": "free137-i046-post-thyroidectomy-hypocalcemia",
      "expectedHashes": {
        "ranaze_step3_uat": "99deeae80c9e3e55faa8767d62505fa43f38b441cada994b97e8e1d36a034df8",
        "ranaze_step3_prd": "99deeae80c9e3e55faa8767d62505fa43f38b441cada994b97e8e1d36a034df8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bilateral extensor plantar responses is inappropriate because extensor plantar responses suggest corticospinal tract disease, not acute postoperative hypocalcemia."
            },
            {
              "id": "B",
              "text": "Option C: Tongue deviation on protrusion is inappropriate because tongue deviation suggests hypoglossal nerve injury, which would not explain perioral and fingertip paresthesias."
            },
            {
              "id": "C",
              "text": "Option D: Left shoulder droop with impaired shrug is inappropriate because shoulder droop suggests spinal accessory nerve injury, not hypocalcemic neuromuscular irritability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bilateral extensor plantar responses is inappropriate because extensor plantar responses suggest corticospinal tract disease, not acute postoperative hypocalcemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tongue deviation on protrusion is inappropriate because tongue deviation suggests hypoglossal nerve injury, which would not explain perioral and fingertip paresthesias."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral extensor plantar responses is inappropriate because extensor plantar responses suggest corticospinal tract disease, not acute postoperative hypocalcemia."
            },
            {
              "id": "C",
              "text": "Option D: Left shoulder droop with impaired shrug is inappropriate because shoulder droop suggests spinal accessory nerve injury, not hypocalcemic neuromuscular irritability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tongue deviation on protrusion is inappropriate because tongue deviation suggests hypoglossal nerve injury, which would not explain perioral and fingertip paresthesias."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Left shoulder droop with impaired shrug is inappropriate because shoulder droop suggests spinal accessory nerve injury, not hypocalcemic neuromuscular irritability."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral extensor plantar responses is inappropriate because extensor plantar responses suggest corticospinal tract disease, not acute postoperative hypocalcemia."
            },
            {
              "id": "C",
              "text": "Option C: Tongue deviation on protrusion is inappropriate because tongue deviation suggests hypoglossal nerve injury, which would not explain perioral and fingertip paresthesias."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Left shoulder droop with impaired shrug is inappropriate because shoulder droop suggests spinal accessory nerve injury, not hypocalcemic neuromuscular irritability."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hypocalcemia causes increased neuromuscular excitability, not diffuse hyporeflexia."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral extensor plantar responses is inappropriate because extensor plantar responses suggest corticospinal tract disease, not acute postoperative hypocalcemia."
            },
            {
              "id": "C",
              "text": "Option C: Tongue deviation on protrusion is inappropriate because tongue deviation suggests hypoglossal nerve injury, which would not explain perioral and fingertip paresthesias."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hypocalcemia causes increased neuromuscular excitability, not diffuse hyporeflexia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unilateral ptosis and miosis is inappropriate because ptosis and miosis suggest Horner syndrome, which does not fit this presentation."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral extensor plantar responses is inappropriate because extensor plantar responses suggest corticospinal tract disease, not acute postoperative hypocalcemia."
            },
            {
              "id": "C",
              "text": "Option C: Tongue deviation on protrusion is inappropriate because tongue deviation suggests hypoglossal nerve injury, which would not explain perioral and fingertip paresthesias."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unilateral ptosis and miosis is inappropriate because ptosis and miosis suggest Horner syndrome, which does not fit this presentation."
        }
      }
    },
    {
      "externalId": "free137-i047-chronic-hip-pain-initial-radiography",
      "expectedHashes": {
        "ranaze_step3_uat": "5acd4d7c3374ecbdd8fc3c5aa3b41362a1a84aaffbab2769b62d2e704f6156d0",
        "ranaze_step3_prd": "5acd4d7c3374ecbdd8fc3c5aa3b41362a1a84aaffbab2769b62d2e704f6156d0"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the hip with contrast is inappropriate because mRI is reserved for nondiagnostic radiographs or suspected occult soft-tissue or marrow disease."
            },
            {
              "id": "B",
              "text": "Option B: CT of the pelvis is inappropriate because cT is not first-line for typical chronic degenerative hip pain."
            },
            {
              "id": "C",
              "text": "Option D: Bone scintigraphy is unnecessary without concern for multifocal or occult osseous disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the hip with contrast is inappropriate because mRI is reserved for nondiagnostic radiographs or suspected occult soft-tissue or marrow disease."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT of the pelvis is inappropriate because cT is not first-line for typical chronic degenerative hip pain."
            },
            {
              "id": "B",
              "text": "Option A: MRI of the hip with contrast is inappropriate because mRI is reserved for nondiagnostic radiographs or suspected occult soft-tissue or marrow disease."
            },
            {
              "id": "C",
              "text": "Option D: Bone scintigraphy is unnecessary without concern for multifocal or occult osseous disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT of the pelvis is inappropriate because cT is not first-line for typical chronic degenerative hip pain."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bone scintigraphy is unnecessary without concern for multifocal or occult osseous disease."
            },
            {
              "id": "B",
              "text": "Option A: MRI of the hip with contrast is inappropriate because mRI is reserved for nondiagnostic radiographs or suspected occult soft-tissue or marrow disease."
            },
            {
              "id": "C",
              "text": "Option B: CT of the pelvis is inappropriate because cT is not first-line for typical chronic degenerative hip pain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bone scintigraphy is unnecessary without concern for multifocal or occult osseous disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hip ultrasonography is inappropriate because ultrasonography may assess effusion or guide injection but does not best evaluate osteoarthritis."
            },
            {
              "id": "B",
              "text": "Option A: MRI of the hip with contrast is inappropriate because mRI is reserved for nondiagnostic radiographs or suspected occult soft-tissue or marrow disease."
            },
            {
              "id": "C",
              "text": "Option B: CT of the pelvis is inappropriate because cT is not first-line for typical chronic degenerative hip pain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hip ultrasonography is inappropriate because ultrasonography may assess effusion or guide injection but does not best evaluate osteoarthritis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electromyography evaluates neuropathy or radiculopathy, which the examination does not suggest."
            },
            {
              "id": "B",
              "text": "Option A: MRI of the hip with contrast is inappropriate because mRI is reserved for nondiagnostic radiographs or suspected occult soft-tissue or marrow disease."
            },
            {
              "id": "C",
              "text": "Option B: CT of the pelvis is inappropriate because cT is not first-line for typical chronic degenerative hip pain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electromyography evaluates neuropathy or radiculopathy, which the examination does not suggest."
        }
      }
    },
    {
      "externalId": "free137-i049-pregnancy-mitral-stenosis-af",
      "expectedHashes": {
        "ranaze_step3_uat": "4242cb6f8056aa7ef51f6af6d6d016b1a1625bf9219db1aa2ea5eeeb815631d1",
        "ranaze_step3_prd": "4242cb6f8056aa7ef51f6af6d6d016b1a1625bf9219db1aa2ea5eeeb815631d1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unrepaired atrial septal defect with pulmonary vascular disease is inappropriate because an atrial septal defect with pulmonary vascular disease does not explain an opening snap followed by a low-pitched apical diastolic rumble."
            },
            {
              "id": "B",
              "text": "Option B: Chronic rheumatic mitral regurgitation is inappropriate because mitral regurgitation typically causes a holosystolic apical murmur rather than an opening snap and diastolic rumble."
            },
            {
              "id": "C",
              "text": "Option C: Coarctation of the aorta causes upper-extremity hypertension and pulse discrepancies, not the described mitral valve findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unrepaired atrial septal defect with pulmonary vascular disease is inappropriate because an atrial septal defect with pulmonary vascular disease does not explain an opening snap followed by a low-pitched apical diastolic rumble."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic rheumatic mitral regurgitation is inappropriate because mitral regurgitation typically causes a holosystolic apical murmur rather than an opening snap and diastolic rumble."
            },
            {
              "id": "B",
              "text": "Option A: Unrepaired atrial septal defect with pulmonary vascular disease is inappropriate because an atrial septal defect with pulmonary vascular disease does not explain an opening snap followed by a low-pitched apical diastolic rumble."
            },
            {
              "id": "C",
              "text": "Option C: Coarctation of the aorta causes upper-extremity hypertension and pulse discrepancies, not the described mitral valve findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic rheumatic mitral regurgitation is inappropriate because mitral regurgitation typically causes a holosystolic apical murmur rather than an opening snap and diastolic rumble."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Coarctation of the aorta causes upper-extremity hypertension and pulse discrepancies, not the described mitral valve findings."
            },
            {
              "id": "B",
              "text": "Option A: Unrepaired atrial septal defect with pulmonary vascular disease is inappropriate because an atrial septal defect with pulmonary vascular disease does not explain an opening snap followed by a low-pitched apical diastolic rumble."
            },
            {
              "id": "C",
              "text": "Option B: Chronic rheumatic mitral regurgitation is inappropriate because mitral regurgitation typically causes a holosystolic apical murmur rather than an opening snap and diastolic rumble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Coarctation of the aorta causes upper-extremity hypertension and pulse discrepancies, not the described mitral valve findings."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Congenital valvular aortic stenosis is inappropriate because aortic stenosis causes a systolic ejection murmur, not an apical diastolic rumble preceded by an opening snap."
            },
            {
              "id": "B",
              "text": "Option A: Unrepaired atrial septal defect with pulmonary vascular disease is inappropriate because an atrial septal defect with pulmonary vascular disease does not explain an opening snap followed by a low-pitched apical diastolic rumble."
            },
            {
              "id": "C",
              "text": "Option B: Chronic rheumatic mitral regurgitation is inappropriate because mitral regurgitation typically causes a holosystolic apical murmur rather than an opening snap and diastolic rumble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Congenital valvular aortic stenosis is inappropriate because aortic stenosis causes a systolic ejection murmur, not an apical diastolic rumble preceded by an opening snap."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Peripartum cardiomyopathy can cause heart failure symptoms late in pregnancy, but it does not account for the opening snap and apical diastolic rumble."
            },
            {
              "id": "B",
              "text": "Option A: Unrepaired atrial septal defect with pulmonary vascular disease is inappropriate because an atrial septal defect with pulmonary vascular disease does not explain an opening snap followed by a low-pitched apical diastolic rumble."
            },
            {
              "id": "C",
              "text": "Option B: Chronic rheumatic mitral regurgitation is inappropriate because mitral regurgitation typically causes a holosystolic apical murmur rather than an opening snap and diastolic rumble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Peripartum cardiomyopathy can cause heart failure symptoms late in pregnancy, but it does not account for the opening snap and apical diastolic rumble."
        }
      }
    },
    {
      "externalId": "free137-i051-chlamydial-pid-tubal-infertility",
      "expectedHashes": {
        "ranaze_step3_uat": "e0492274fb5335472fb937b42baf41b1ada12c3980a27495997af38bcb1772f1",
        "ranaze_step3_prd": "e0492274fb5335472fb937b42baf41b1ada12c3980a27495997af38bcb1772f1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intermittent bacterial vaginosis is inappropriate because bacterial vaginosis alone does not typically cause bilateral tubal occlusion."
            },
            {
              "id": "B",
              "text": "Option C: Use of a copper intrauterine device for 2 years is inappropriate because an intrauterine device does not cause chronic tubal infertility after the brief insertion-related infection risk."
            },
            {
              "id": "C",
              "text": "Option D: Remote uncomplicated cystitis is inappropriate because lower urinary infection does not scar the fallopian tubes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intermittent bacterial vaginosis is inappropriate because bacterial vaginosis alone does not typically cause bilateral tubal occlusion."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use of a copper intrauterine device for 2 years is inappropriate because an intrauterine device does not cause chronic tubal infertility after the brief insertion-related infection risk."
            },
            {
              "id": "B",
              "text": "Option B: Intermittent bacterial vaginosis is inappropriate because bacterial vaginosis alone does not typically cause bilateral tubal occlusion."
            },
            {
              "id": "C",
              "text": "Option D: Remote uncomplicated cystitis is inappropriate because lower urinary infection does not scar the fallopian tubes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use of a copper intrauterine device for 2 years is inappropriate because an intrauterine device does not cause chronic tubal infertility after the brief insertion-related infection risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remote uncomplicated cystitis is inappropriate because lower urinary infection does not scar the fallopian tubes."
            },
            {
              "id": "B",
              "text": "Option B: Intermittent bacterial vaginosis is inappropriate because bacterial vaginosis alone does not typically cause bilateral tubal occlusion."
            },
            {
              "id": "C",
              "text": "Option C: Use of a copper intrauterine device for 2 years is inappropriate because an intrauterine device does not cause chronic tubal infertility after the brief insertion-related infection risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remote uncomplicated cystitis is inappropriate because lower urinary infection does not scar the fallopian tubes."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prior vulvovaginal candidiasis is inappropriate because candidiasis is confined to the vulvovaginal mucosa and does not cause tubal damage."
            },
            {
              "id": "B",
              "text": "Option B: Intermittent bacterial vaginosis is inappropriate because bacterial vaginosis alone does not typically cause bilateral tubal occlusion."
            },
            {
              "id": "C",
              "text": "Option C: Use of a copper intrauterine device for 2 years is inappropriate because an intrauterine device does not cause chronic tubal infertility after the brief insertion-related infection risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prior vulvovaginal candidiasis is inappropriate because candidiasis is confined to the vulvovaginal mucosa and does not cause tubal damage."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Regular use of barrier contraception is inappropriate because barrier contraception reduces sexually transmitted infection risk rather than causing infertility."
            },
            {
              "id": "B",
              "text": "Option B: Intermittent bacterial vaginosis is inappropriate because bacterial vaginosis alone does not typically cause bilateral tubal occlusion."
            },
            {
              "id": "C",
              "text": "Option C: Use of a copper intrauterine device for 2 years is inappropriate because an intrauterine device does not cause chronic tubal infertility after the brief insertion-related infection risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Regular use of barrier contraception is inappropriate because barrier contraception reduces sexually transmitted infection risk rather than causing infertility."
        }
      }
    },
    {
      "externalId": "free137-i052-vitamin-d-myalgias-osteoporosis",
      "expectedHashes": {
        "ranaze_step3_uat": "c9f90aad6f816850e19ef4fd4a7beecd4ce28c365f773c10d749da4730ce2429",
        "ranaze_step3_prd": "c9f90aad6f816850e19ef4fd4a7beecd4ce28c365f773c10d749da4730ce2429"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat dual-energy x-ray absorptiometry scan now is inappropriate because bone density monitoring may be appropriate for osteoporosis follow-up, but it does not evaluate the cause of diffuse bone pain and myalgias."
            },
            {
              "id": "B",
              "text": "Option B: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next step without focal weakness or neuropathic findings."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the cervical spine is inappropriate because cervical spine MRI is not indicated without focal neurologic symptoms or examination abnormalities."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat dual-energy x-ray absorptiometry scan now is inappropriate because bone density monitoring may be appropriate for osteoporosis follow-up, but it does not evaluate the cause of diffuse bone pain and myalgias."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next step without focal weakness or neuropathic findings."
            },
            {
              "id": "B",
              "text": "Option A: Repeat dual-energy x-ray absorptiometry scan now is inappropriate because bone density monitoring may be appropriate for osteoporosis follow-up, but it does not evaluate the cause of diffuse bone pain and myalgias."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the cervical spine is inappropriate because cervical spine MRI is not indicated without focal neurologic symptoms or examination abnormalities."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next step without focal weakness or neuropathic findings."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the cervical spine is inappropriate because cervical spine MRI is not indicated without focal neurologic symptoms or examination abnormalities."
            },
            {
              "id": "B",
              "text": "Option A: Repeat dual-energy x-ray absorptiometry scan now is inappropriate because bone density monitoring may be appropriate for osteoporosis follow-up, but it does not evaluate the cause of diffuse bone pain and myalgias."
            },
            {
              "id": "C",
              "text": "Option B: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next step without focal weakness or neuropathic findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the cervical spine is inappropriate because cervical spine MRI is not indicated without focal neurologic symptoms or examination abnormalities."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum antinuclear antibody assay is inappropriate because aNA testing is low yield without specific autoimmune features on history or examination."
            },
            {
              "id": "B",
              "text": "Option A: Repeat dual-energy x-ray absorptiometry scan now is inappropriate because bone density monitoring may be appropriate for osteoporosis follow-up, but it does not evaluate the cause of diffuse bone pain and myalgias."
            },
            {
              "id": "C",
              "text": "Option B: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next step without focal weakness or neuropathic findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum antinuclear antibody assay is inappropriate because aNA testing is low yield without specific autoimmune features on history or examination."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No additional evaluation is indicated is inappropriate because further evaluation is indicated because a common, reversible cause of diffuse musculoskeletal symptoms remains unassessed."
            },
            {
              "id": "B",
              "text": "Option A: Repeat dual-energy x-ray absorptiometry scan now is inappropriate because bone density monitoring may be appropriate for osteoporosis follow-up, but it does not evaluate the cause of diffuse bone pain and myalgias."
            },
            {
              "id": "C",
              "text": "Option B: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next step without focal weakness or neuropathic findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No additional evaluation is indicated is inappropriate because further evaluation is indicated because a common, reversible cause of diffuse musculoskeletal symptoms remains unassessed."
        }
      }
    },
    {
      "externalId": "free137-i053-viral-rhinosinusitis-mucosal-edema",
      "expectedHashes": {
        "ranaze_step3_uat": "d54fb1adace962f5bb2c6adfefd8eae7dcf613633cec8e03465e6924e1356ac6",
        "ranaze_step3_prd": "d54fb1adace962f5bb2c6adfefd8eae7dcf613633cec8e03465e6924e1356ac6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mechanical obstruction by a nasal polyp is inappropriate because a nasal polyp is a structural cause of obstruction, but this patient has an acute URI-type presentation without a history suggesting chronic polyp disease."
            },
            {
              "id": "B",
              "text": "Option C: Hormonal effect of oral contraceptive use is inappropriate because oral contraceptive use is not a typical mechanism of acute rhinosinusitis in an otherwise healthy patient with a brief URI-like illness."
            },
            {
              "id": "C",
              "text": "Option D: Primary eustachian tube dysfunction is inappropriate because eustachian tube dysfunction can explain the middle-ear effusion but not the primary maxillary sinus process."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mechanical obstruction by a nasal polyp is inappropriate because a nasal polyp is a structural cause of obstruction, but this patient has an acute URI-type presentation without a history suggesting chronic polyp disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hormonal effect of oral contraceptive use is inappropriate because oral contraceptive use is not a typical mechanism of acute rhinosinusitis in an otherwise healthy patient with a brief URI-like illness."
            },
            {
              "id": "B",
              "text": "Option A: Mechanical obstruction by a nasal polyp is inappropriate because a nasal polyp is a structural cause of obstruction, but this patient has an acute URI-type presentation without a history suggesting chronic polyp disease."
            },
            {
              "id": "C",
              "text": "Option D: Primary eustachian tube dysfunction is inappropriate because eustachian tube dysfunction can explain the middle-ear effusion but not the primary maxillary sinus process."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hormonal effect of oral contraceptive use is inappropriate because oral contraceptive use is not a typical mechanism of acute rhinosinusitis in an otherwise healthy patient with a brief URI-like illness."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Primary eustachian tube dysfunction is inappropriate because eustachian tube dysfunction can explain the middle-ear effusion but not the primary maxillary sinus process."
            },
            {
              "id": "B",
              "text": "Option A: Mechanical obstruction by a nasal polyp is inappropriate because a nasal polyp is a structural cause of obstruction, but this patient has an acute URI-type presentation without a history suggesting chronic polyp disease."
            },
            {
              "id": "C",
              "text": "Option C: Hormonal effect of oral contraceptive use is inappropriate because oral contraceptive use is not a typical mechanism of acute rhinosinusitis in an otherwise healthy patient with a brief URI-like illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Primary eustachian tube dysfunction is inappropriate because eustachian tube dysfunction can explain the middle-ear effusion but not the primary maxillary sinus process."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tonsillar enlargement causing outflow obstruction is inappropriate because tonsillar enlargement can accompany pharyngitis but does not explain the focal maxillary sinus tenderness and dental pain."
            },
            {
              "id": "B",
              "text": "Option A: Mechanical obstruction by a nasal polyp is inappropriate because a nasal polyp is a structural cause of obstruction, but this patient has an acute URI-type presentation without a history suggesting chronic polyp disease."
            },
            {
              "id": "C",
              "text": "Option C: Hormonal effect of oral contraceptive use is inappropriate because oral contraceptive use is not a typical mechanism of acute rhinosinusitis in an otherwise healthy patient with a brief URI-like illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tonsillar enlargement causing outflow obstruction is inappropriate because tonsillar enlargement can accompany pharyngitis but does not explain the focal maxillary sinus tenderness and dental pain."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Impaired mucociliary clearance from tobacco exposure is inappropriate because smoking can impair mucociliary clearance, but this patient does not smoke and the illness is acute."
            },
            {
              "id": "B",
              "text": "Option A: Mechanical obstruction by a nasal polyp is inappropriate because a nasal polyp is a structural cause of obstruction, but this patient has an acute URI-type presentation without a history suggesting chronic polyp disease."
            },
            {
              "id": "C",
              "text": "Option C: Hormonal effect of oral contraceptive use is inappropriate because oral contraceptive use is not a typical mechanism of acute rhinosinusitis in an otherwise healthy patient with a brief URI-like illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Impaired mucociliary clearance from tobacco exposure is inappropriate because smoking can impair mucociliary clearance, but this patient does not smoke and the illness is acute."
        }
      }
    },
    {
      "externalId": "free137-i054-deceptive-placebo-autonomy",
      "expectedHashes": {
        "ranaze_step3_uat": "d7a60655cb8073fc805c7b2221849bf9a7d81651439c1ee31a6bff7d23220931",
        "ranaze_step3_prd": "d7a60655cb8073fc805c7b2221849bf9a7d81651439c1ee31a6bff7d23220931"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The treatment was too inexpensive is inappropriate because cost is not the ethical issue."
            },
            {
              "id": "B",
              "text": "Option C: Functional symptoms must never be treated is inappropriate because functional neurologic symptoms should be treated with transparent, evidence-based care."
            },
            {
              "id": "C",
              "text": "Option D: A placebo may be used only in hospitalized patients is inappropriate because the care setting does not make deception acceptable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The treatment was too inexpensive is inappropriate because cost is not the ethical issue."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Functional symptoms must never be treated is inappropriate because functional neurologic symptoms should be treated with transparent, evidence-based care."
            },
            {
              "id": "B",
              "text": "Option A: The treatment was too inexpensive is inappropriate because cost is not the ethical issue."
            },
            {
              "id": "C",
              "text": "Option D: A placebo may be used only in hospitalized patients is inappropriate because the care setting does not make deception acceptable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Functional symptoms must never be treated is inappropriate because functional neurologic symptoms should be treated with transparent, evidence-based care."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A placebo may be used only in hospitalized patients is inappropriate because the care setting does not make deception acceptable."
            },
            {
              "id": "B",
              "text": "Option A: The treatment was too inexpensive is inappropriate because cost is not the ethical issue."
            },
            {
              "id": "C",
              "text": "Option C: Functional symptoms must never be treated is inappropriate because functional neurologic symptoms should be treated with transparent, evidence-based care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A placebo may be used only in hospitalized patients is inappropriate because the care setting does not make deception acceptable."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Improvement proves the patient was malingering is inappropriate because response to suggestion does not establish intentional symptom production."
            },
            {
              "id": "B",
              "text": "Option A: The treatment was too inexpensive is inappropriate because cost is not the ethical issue."
            },
            {
              "id": "C",
              "text": "Option C: Functional symptoms must never be treated is inappropriate because functional neurologic symptoms should be treated with transparent, evidence-based care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Improvement proves the patient was malingering is inappropriate because response to suggestion does not establish intentional symptom production."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The physician should have disclosed the intervention only afterward is inappropriate because disclosure after deception does not provide prospective informed consent."
            },
            {
              "id": "B",
              "text": "Option A: The treatment was too inexpensive is inappropriate because cost is not the ethical issue."
            },
            {
              "id": "C",
              "text": "Option C: Functional symptoms must never be treated is inappropriate because functional neurologic symptoms should be treated with transparent, evidence-based care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The physician should have disclosed the intervention only afterward is inappropriate because disclosure after deception does not provide prospective informed consent."
        }
      }
    },
    {
      "externalId": "free137-i057-stereotyped-alcohol-withdrawal-seizure-evaluation",
      "expectedHashes": {
        "ranaze_step3_uat": "8134b5bebb0a2b32e247a0b64622866c6b3d34fbce44da530cfa30dad21a5cdd",
        "ranaze_step3_prd": "8134b5bebb0a2b32e247a0b64622866c6b3d34fbce44da530cfa30dad21a5cdd"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urgent brain MRI is inappropriate because mRI is reserved for a new seizure pattern, focal findings, trauma, or another suspected cause."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture is not indicated without fever, meningismus, or persistent altered mental status."
            },
            {
              "id": "C",
              "text": "Option C: Electroencephalography before discharge is inappropriate because routine EEG is unnecessary for a classic recurrent withdrawal seizure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urgent brain MRI is inappropriate because mRI is reserved for a new seizure pattern, focal findings, trauma, or another suspected cause."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar puncture is not indicated without fever, meningismus, or persistent altered mental status."
            },
            {
              "id": "B",
              "text": "Option A: Urgent brain MRI is inappropriate because mRI is reserved for a new seizure pattern, focal findings, trauma, or another suspected cause."
            },
            {
              "id": "C",
              "text": "Option C: Electroencephalography before discharge is inappropriate because routine EEG is unnecessary for a classic recurrent withdrawal seizure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar puncture is not indicated without fever, meningismus, or persistent altered mental status."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electroencephalography before discharge is inappropriate because routine EEG is unnecessary for a classic recurrent withdrawal seizure."
            },
            {
              "id": "B",
              "text": "Option A: Urgent brain MRI is inappropriate because mRI is reserved for a new seizure pattern, focal findings, trauma, or another suspected cause."
            },
            {
              "id": "C",
              "text": "Option B: Lumbar puncture is not indicated without fever, meningismus, or persistent altered mental status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electroencephalography before discharge is inappropriate because routine EEG is unnecessary for a classic recurrent withdrawal seizure."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cerebral angiography is inappropriate because angiography is not indicated without evidence of a vascular lesion."
            },
            {
              "id": "B",
              "text": "Option A: Urgent brain MRI is inappropriate because mRI is reserved for a new seizure pattern, focal findings, trauma, or another suspected cause."
            },
            {
              "id": "C",
              "text": "Option B: Lumbar puncture is not indicated without fever, meningismus, or persistent altered mental status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cerebral angiography is inappropriate because angiography is not indicated without evidence of a vascular lesion."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat head CT every 6 hours is inappropriate because serial CT imaging adds radiation without an indication."
            },
            {
              "id": "B",
              "text": "Option A: Urgent brain MRI is inappropriate because mRI is reserved for a new seizure pattern, focal findings, trauma, or another suspected cause."
            },
            {
              "id": "C",
              "text": "Option B: Lumbar puncture is not indicated without fever, meningismus, or persistent altered mental status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat head CT every 6 hours is inappropriate because serial CT imaging adds radiation without an indication."
        }
      }
    },
    {
      "externalId": "free137-i058-hiv-lobar-pneumonia-pneumococcus",
      "expectedHashes": {
        "ranaze_step3_uat": "02298244499f85a50eb210a821372390a8d2f92504c4a84b1c174699c09163fc",
        "ranaze_step3_prd": "02298244499f85a50eb210a821372390a8d2f92504c4a84b1c174699c09163fc"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Legionella pneumonia is inappropriate because legionella can cause community-acquired pneumonia, but this vignette shows a classic focal lobar bacterial pattern without distinctive extrapulmonary clues."
            },
            {
              "id": "B",
              "text": "Option B: Pneumocystis jirovecii pneumonia usually causes a more diffuse, nonlobar process with nonfocal examination findings rather than dense right lower-lobe consolidation."
            },
            {
              "id": "C",
              "text": "Option D: Pulmonary embolism can cause dyspnea and pleuritic symptoms, but it does not best explain focal bronchial breath sounds, dullness, and lobar consolidation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Legionella pneumonia is inappropriate because legionella can cause community-acquired pneumonia, but this vignette shows a classic focal lobar bacterial pattern without distinctive extrapulmonary clues."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pneumocystis jirovecii pneumonia usually causes a more diffuse, nonlobar process with nonfocal examination findings rather than dense right lower-lobe consolidation."
            },
            {
              "id": "B",
              "text": "Option A: Legionella pneumonia is inappropriate because legionella can cause community-acquired pneumonia, but this vignette shows a classic focal lobar bacterial pattern without distinctive extrapulmonary clues."
            },
            {
              "id": "C",
              "text": "Option D: Pulmonary embolism can cause dyspnea and pleuritic symptoms, but it does not best explain focal bronchial breath sounds, dullness, and lobar consolidation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pneumocystis jirovecii pneumonia usually causes a more diffuse, nonlobar process with nonfocal examination findings rather than dense right lower-lobe consolidation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary embolism can cause dyspnea and pleuritic symptoms, but it does not best explain focal bronchial breath sounds, dullness, and lobar consolidation."
            },
            {
              "id": "B",
              "text": "Option A: Legionella pneumonia is inappropriate because legionella can cause community-acquired pneumonia, but this vignette shows a classic focal lobar bacterial pattern without distinctive extrapulmonary clues."
            },
            {
              "id": "C",
              "text": "Option B: Pneumocystis jirovecii pneumonia usually causes a more diffuse, nonlobar process with nonfocal examination findings rather than dense right lower-lobe consolidation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary embolism can cause dyspnea and pleuritic symptoms, but it does not best explain focal bronchial breath sounds, dullness, and lobar consolidation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary tuberculosis is inappropriate because tuberculosis is usually more indolent and often has a different radiographic pattern than abrupt focal lobar consolidation."
            },
            {
              "id": "B",
              "text": "Option A: Legionella pneumonia is inappropriate because legionella can cause community-acquired pneumonia, but this vignette shows a classic focal lobar bacterial pattern without distinctive extrapulmonary clues."
            },
            {
              "id": "C",
              "text": "Option B: Pneumocystis jirovecii pneumonia usually causes a more diffuse, nonlobar process with nonfocal examination findings rather than dense right lower-lobe consolidation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary tuberculosis is inappropriate because tuberculosis is usually more indolent and often has a different radiographic pattern than abrupt focal lobar consolidation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Septic pulmonary emboli more often cause multiple peripheral nodules or cavitary lesions rather than a single dense lobar consolidation."
            },
            {
              "id": "B",
              "text": "Option A: Legionella pneumonia is inappropriate because legionella can cause community-acquired pneumonia, but this vignette shows a classic focal lobar bacterial pattern without distinctive extrapulmonary clues."
            },
            {
              "id": "C",
              "text": "Option B: Pneumocystis jirovecii pneumonia usually causes a more diffuse, nonlobar process with nonfocal examination findings rather than dense right lower-lobe consolidation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Septic pulmonary emboli more often cause multiple peripheral nodules or cavitary lesions rather than a single dense lobar consolidation."
        }
      }
    },
    {
      "externalId": "free137-i061-klinefelter-confirmation",
      "expectedHashes": {
        "ranaze_step3_uat": "39ca1d19d4b83179c4191b3ffb085e2dde1502c33775b0fca752d09c2e3068c8",
        "ranaze_step3_prd": "39ca1d19d4b83179c4191b3ffb085e2dde1502c33775b0fca752d09c2e3068c8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum total testosterone concentration is inappropriate because testosterone may be low, but a hormone level alone does not establish the chromosomal diagnosis."
            },
            {
              "id": "B",
              "text": "Option C: Serum follicle-stimulating hormone and luteinizing hormone concentrations is inappropriate because fSH and LH are often elevated in primary testicular failure, but they are supportive findings rather than the confirmatory test."
            },
            {
              "id": "C",
              "text": "Option D: Serum prolactin concentration is inappropriate because prolactin testing is not the best study for this phenotype of infertility with small firm testes and gynecomastia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum total testosterone concentration is inappropriate because testosterone may be low, but a hormone level alone does not establish the chromosomal diagnosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum follicle-stimulating hormone and luteinizing hormone concentrations is inappropriate because fSH and LH are often elevated in primary testicular failure, but they are supportive findings rather than the confirmatory test."
            },
            {
              "id": "B",
              "text": "Option B: Serum total testosterone concentration is inappropriate because testosterone may be low, but a hormone level alone does not establish the chromosomal diagnosis."
            },
            {
              "id": "C",
              "text": "Option D: Serum prolactin concentration is inappropriate because prolactin testing is not the best study for this phenotype of infertility with small firm testes and gynecomastia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum follicle-stimulating hormone and luteinizing hormone concentrations is inappropriate because fSH and LH are often elevated in primary testicular failure, but they are supportive findings rather than the confirmatory test."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum prolactin concentration is inappropriate because prolactin testing is not the best study for this phenotype of infertility with small firm testes and gynecomastia."
            },
            {
              "id": "B",
              "text": "Option B: Serum total testosterone concentration is inappropriate because testosterone may be low, but a hormone level alone does not establish the chromosomal diagnosis."
            },
            {
              "id": "C",
              "text": "Option C: Serum follicle-stimulating hormone and luteinizing hormone concentrations is inappropriate because fSH and LH are often elevated in primary testicular failure, but they are supportive findings rather than the confirmatory test."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum prolactin concentration is inappropriate because prolactin testing is not the best study for this phenotype of infertility with small firm testes and gynecomastia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Scrotal ultrasonography is inappropriate because ultrasonography can describe anatomy but does not determine the chromosomal cause of this pattern."
            },
            {
              "id": "B",
              "text": "Option B: Serum total testosterone concentration is inappropriate because testosterone may be low, but a hormone level alone does not establish the chromosomal diagnosis."
            },
            {
              "id": "C",
              "text": "Option C: Serum follicle-stimulating hormone and luteinizing hormone concentrations is inappropriate because fSH and LH are often elevated in primary testicular failure, but they are supportive findings rather than the confirmatory test."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Scrotal ultrasonography is inappropriate because ultrasonography can describe anatomy but does not determine the chromosomal cause of this pattern."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CFTR mutation analysis is inappropriate because cFTR testing is used when congenital absence of the vas deferens is suspected; that does not fit this phenotype."
            },
            {
              "id": "B",
              "text": "Option B: Serum total testosterone concentration is inappropriate because testosterone may be low, but a hormone level alone does not establish the chromosomal diagnosis."
            },
            {
              "id": "C",
              "text": "Option C: Serum follicle-stimulating hormone and luteinizing hormone concentrations is inappropriate because fSH and LH are often elevated in primary testicular failure, but they are supportive findings rather than the confirmatory test."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CFTR mutation analysis is inappropriate because cFTR testing is used when congenital absence of the vas deferens is suspected; that does not fit this phenotype."
        }
      }
    },
    {
      "externalId": "free137-i068-tricuspid-regurgitation-inspiration",
      "expectedHashes": {
        "ranaze_step3_uat": "40204cd8fc5eb7185821dabccfc62ff2ab100322536560286d19e34167982d2d",
        "ranaze_step3_prd": "40204cd8fc5eb7185821dabccfc62ff2ab100322536560286d19e34167982d2d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase in murmur intensity with forced expiration is inappropriate because forced expiration more often accentuates left-sided murmurs, not the right-sided murmur suggested here."
            },
            {
              "id": "B",
              "text": "Option C: Opening snap followed by a diastolic rumble at the apex is inappropriate because an opening snap with an apical diastolic rumble suggests mitral stenosis, not the lesion implied by this stem."
            },
            {
              "id": "C",
              "text": "Option D: Markedly diminished carotid upstroke is inappropriate because diminished carotid upstroke is associated with severe aortic stenosis, not this left lower sternal border holosystolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase in murmur intensity with forced expiration is inappropriate because forced expiration more often accentuates left-sided murmurs, not the right-sided murmur suggested here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Opening snap followed by a diastolic rumble at the apex is inappropriate because an opening snap with an apical diastolic rumble suggests mitral stenosis, not the lesion implied by this stem."
            },
            {
              "id": "B",
              "text": "Option B: Increase in murmur intensity with forced expiration is inappropriate because forced expiration more often accentuates left-sided murmurs, not the right-sided murmur suggested here."
            },
            {
              "id": "C",
              "text": "Option D: Markedly diminished carotid upstroke is inappropriate because diminished carotid upstroke is associated with severe aortic stenosis, not this left lower sternal border holosystolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Opening snap followed by a diastolic rumble at the apex is inappropriate because an opening snap with an apical diastolic rumble suggests mitral stenosis, not the lesion implied by this stem."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Markedly diminished carotid upstroke is inappropriate because diminished carotid upstroke is associated with severe aortic stenosis, not this left lower sternal border holosystolic murmur."
            },
            {
              "id": "B",
              "text": "Option B: Increase in murmur intensity with forced expiration is inappropriate because forced expiration more often accentuates left-sided murmurs, not the right-sided murmur suggested here."
            },
            {
              "id": "C",
              "text": "Option C: Opening snap followed by a diastolic rumble at the apex is inappropriate because an opening snap with an apical diastolic rumble suggests mitral stenosis, not the lesion implied by this stem."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Markedly diminished carotid upstroke is inappropriate because diminished carotid upstroke is associated with severe aortic stenosis, not this left lower sternal border holosystolic murmur."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wide fixed splitting of the second heart sound is inappropriate because wide fixed splitting of S2 is characteristic of an atrial septal defect, not this acute presentation."
            },
            {
              "id": "B",
              "text": "Option B: Increase in murmur intensity with forced expiration is inappropriate because forced expiration more often accentuates left-sided murmurs, not the right-sided murmur suggested here."
            },
            {
              "id": "C",
              "text": "Option C: Opening snap followed by a diastolic rumble at the apex is inappropriate because an opening snap with an apical diastolic rumble suggests mitral stenosis, not the lesion implied by this stem."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wide fixed splitting of the second heart sound is inappropriate because wide fixed splitting of S2 is characteristic of an atrial septal defect, not this acute presentation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decrease in murmur intensity with deep inspiration is inappropriate because right-sided murmurs generally become louder, not softer, with inspiration."
            },
            {
              "id": "B",
              "text": "Option B: Increase in murmur intensity with forced expiration is inappropriate because forced expiration more often accentuates left-sided murmurs, not the right-sided murmur suggested here."
            },
            {
              "id": "C",
              "text": "Option C: Opening snap followed by a diastolic rumble at the apex is inappropriate because an opening snap with an apical diastolic rumble suggests mitral stenosis, not the lesion implied by this stem."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decrease in murmur intensity with deep inspiration is inappropriate because right-sided murmurs generally become louder, not softer, with inspiration."
        }
      }
    },
    {
      "externalId": "free137-i069-latex-free-catheter-precaution",
      "expectedHashes": {
        "ranaze_step3_uat": "8c412925c8f258273d990f1719e191dbdb35e222f0549d6a249f9724fb03dfb9",
        "ranaze_step3_prd": "8c412925c8f258273d990f1719e191dbdb35e222f0549d6a249f9724fb03dfb9"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Switch from disposable syringes to glass syringes is inappropriate because changing syringe type does not address the patient\u0027s known severe latex-triggered perioperative reaction during a procedure involving urinary instrumentation."
            },
            {
              "id": "B",
              "text": "Option C: Request meals prepared by an outside food service is inappropriate because food sourcing is not the immediate perioperative hazard described here; the urgent risk is exposure to latex-containing medical equipment."
            },
            {
              "id": "C",
              "text": "Option D: Change the detergent used for the hospital linens is inappropriate because changing linen detergent does not address this patient\u0027s prior severe systemic reaction to natural rubber latex during an operation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Switch from disposable syringes to glass syringes is inappropriate because changing syringe type does not address the patient\u0027s known severe latex-triggered perioperative reaction during a procedure involving urinary instrumentation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request meals prepared by an outside food service is inappropriate because food sourcing is not the immediate perioperative hazard described here; the urgent risk is exposure to latex-containing medical equipment."
            },
            {
              "id": "B",
              "text": "Option A: Switch from disposable syringes to glass syringes is inappropriate because changing syringe type does not address the patient\u0027s known severe latex-triggered perioperative reaction during a procedure involving urinary instrumentation."
            },
            {
              "id": "C",
              "text": "Option D: Change the detergent used for the hospital linens is inappropriate because changing linen detergent does not address this patient\u0027s prior severe systemic reaction to natural rubber latex during an operation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request meals prepared by an outside food service is inappropriate because food sourcing is not the immediate perioperative hazard described here; the urgent risk is exposure to latex-containing medical equipment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Change the detergent used for the hospital linens is inappropriate because changing linen detergent does not address this patient\u0027s prior severe systemic reaction to natural rubber latex during an operation."
            },
            {
              "id": "B",
              "text": "Option A: Switch from disposable syringes to glass syringes is inappropriate because changing syringe type does not address the patient\u0027s known severe latex-triggered perioperative reaction during a procedure involving urinary instrumentation."
            },
            {
              "id": "C",
              "text": "Option C: Request meals prepared by an outside food service is inappropriate because food sourcing is not the immediate perioperative hazard described here; the urgent risk is exposure to latex-containing medical equipment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Change the detergent used for the hospital linens is inappropriate because changing linen detergent does not address this patient\u0027s prior severe systemic reaction to natural rubber latex during an operation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply emollient cream to the legs before the procedure is inappropriate because moisturizer may help dry skin, but it does not reduce the risk of life-threatening latex exposure during instrumentation."
            },
            {
              "id": "B",
              "text": "Option A: Switch from disposable syringes to glass syringes is inappropriate because changing syringe type does not address the patient\u0027s known severe latex-triggered perioperative reaction during a procedure involving urinary instrumentation."
            },
            {
              "id": "C",
              "text": "Option C: Request meals prepared by an outside food service is inappropriate because food sourcing is not the immediate perioperative hazard described here; the urgent risk is exposure to latex-containing medical equipment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply emollient cream to the legs before the procedure is inappropriate because moisturizer may help dry skin, but it does not reduce the risk of life-threatening latex exposure during instrumentation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pad the bed rails with additional blankets is inappropriate because extra padding may improve comfort, but it does not address the main perioperative danger in this patient."
            },
            {
              "id": "B",
              "text": "Option A: Switch from disposable syringes to glass syringes is inappropriate because changing syringe type does not address the patient\u0027s known severe latex-triggered perioperative reaction during a procedure involving urinary instrumentation."
            },
            {
              "id": "C",
              "text": "Option C: Request meals prepared by an outside food service is inappropriate because food sourcing is not the immediate perioperative hazard described here; the urgent risk is exposure to latex-containing medical equipment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pad the bed rails with additional blankets is inappropriate because extra padding may improve comfort, but it does not address the main perioperative danger in this patient."
        }
      }
    },
    {
      "externalId": "free137-i070-postcolectomy-splenic-bleeding",
      "expectedHashes": {
        "ranaze_step3_uat": "fec3a8a7c28937eb6fd9ab60800705e1e10231db74b11c4b156f47d3093b1ea0",
        "ranaze_step3_prd": "fec3a8a7c28937eb6fd9ab60800705e1e10231db74b11c4b156f47d3093b1ea0"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Common bile duct injury does not fit the operative field and would not best explain this immediate hemorrhagic presentation."
            },
            {
              "id": "B",
              "text": "Option B: Left ureter injury is a recognized colorectal complication, but it does not typically cause a rapid hematocrit drop with shock from concealed intraperitoneal bleeding."
            },
            {
              "id": "C",
              "text": "Option C: Middle colic artery injury is less likely than splenic injury in a case centered on difficult splenic-flexure mobilization with occult postoperative blood loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Common bile duct injury does not fit the operative field and would not best explain this immediate hemorrhagic presentation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Left ureter injury is a recognized colorectal complication, but it does not typically cause a rapid hematocrit drop with shock from concealed intraperitoneal bleeding."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct injury does not fit the operative field and would not best explain this immediate hemorrhagic presentation."
            },
            {
              "id": "C",
              "text": "Option C: Middle colic artery injury is less likely than splenic injury in a case centered on difficult splenic-flexure mobilization with occult postoperative blood loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Left ureter injury is a recognized colorectal complication, but it does not typically cause a rapid hematocrit drop with shock from concealed intraperitoneal bleeding."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Middle colic artery injury is less likely than splenic injury in a case centered on difficult splenic-flexure mobilization with occult postoperative blood loss."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct injury does not fit the operative field and would not best explain this immediate hemorrhagic presentation."
            },
            {
              "id": "C",
              "text": "Option B: Left ureter injury is a recognized colorectal complication, but it does not typically cause a rapid hematocrit drop with shock from concealed intraperitoneal bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Middle colic artery injury is less likely than splenic injury in a case centered on difficult splenic-flexure mobilization with occult postoperative blood loss."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pancreatic tail injury can occur nearby, but this presentation most strongly indicates major hemorrhage from splenic trauma."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct injury does not fit the operative field and would not best explain this immediate hemorrhagic presentation."
            },
            {
              "id": "C",
              "text": "Option B: Left ureter injury is a recognized colorectal complication, but it does not typically cause a rapid hematocrit drop with shock from concealed intraperitoneal bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pancreatic tail injury can occur nearby, but this presentation most strongly indicates major hemorrhage from splenic trauma."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urinary bladder is inappropriate because bladder injury is remote from this operative field and does not best explain the marked hematocrit fall and abdominal distention."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct injury does not fit the operative field and would not best explain this immediate hemorrhagic presentation."
            },
            {
              "id": "C",
              "text": "Option B: Left ureter injury is a recognized colorectal complication, but it does not typically cause a rapid hematocrit drop with shock from concealed intraperitoneal bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urinary bladder is inappropriate because bladder injury is remote from this operative field and does not best explain the marked hematocrit fall and abdominal distention."
        }
      }
    },
    {
      "externalId": "free137-i071-power-from-beta",
      "expectedHashes": {
        "ranaze_step3_uat": "2304e315aaf63f3675180c26ca75ee02f3d9a890168ccc5064876e12e0a7f6f1",
        "ranaze_step3_prd": "2304e315aaf63f3675180c26ca75ee02f3d9a890168ccc5064876e12e0a7f6f1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "1% is the type I error rate described in the stem, not the study power."
            },
            {
              "id": "B",
              "text": "Option B: 10% is beta, the type II error rate, not the power."
            },
            {
              "id": "C",
              "text": "Option C: 50% does not follow from the information provided."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "1% is the type I error rate described in the stem, not the study power."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "10% is beta, the type II error rate, not the power."
            },
            {
              "id": "B",
              "text": "Option A: 1% is the type I error rate described in the stem, not the study power."
            },
            {
              "id": "C",
              "text": "Option C: 50% does not follow from the information provided."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "10% is beta, the type II error rate, not the power."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "50% does not follow from the information provided."
            },
            {
              "id": "B",
              "text": "Option A: 1% is the type I error rate described in the stem, not the study power."
            },
            {
              "id": "C",
              "text": "Option B: 10% is beta, the type II error rate, not the power."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "50% does not follow from the information provided."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "80% would correspond to a beta of 20%, which is not what the stem states."
            },
            {
              "id": "B",
              "text": "Option A: 1% is the type I error rate described in the stem, not the study power."
            },
            {
              "id": "C",
              "text": "Option B: 10% is beta, the type II error rate, not the power."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "80% would correspond to a beta of 20%, which is not what the stem states."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "99% would correspond to a beta of 1%, not 10%."
            },
            {
              "id": "B",
              "text": "Option A: 1% is the type I error rate described in the stem, not the study power."
            },
            {
              "id": "C",
              "text": "Option B: 10% is beta, the type II error rate, not the power."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "99% would correspond to a beta of 1%, not 10%."
        }
      }
    },
    {
      "externalId": "free137-i072-recurrent-anterior-shoulder-instability",
      "expectedHashes": {
        "ranaze_step3_uat": "7c6e0829634d7ac3a121d8b9b541a8cde62e1fab0448ba5d4360cb99f28b687d",
        "ranaze_step3_prd": "7c6e0829634d7ac3a121d8b9b541a8cde62e1fab0448ba5d4360cb99f28b687d"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acromioclavicular joint cartilage is inappropriate because acromioclavicular joint injury causes pain at the AC joint, not recurrent anterior glenohumeral instability."
            },
            {
              "id": "B",
              "text": "Option C: Deltoid muscle fibers is inappropriate because deltoid injury can impair shoulder movement, but it is not the usual cause of recurrent traumatic anterior instability."
            },
            {
              "id": "C",
              "text": "Option D: Long head of the triceps tendon is inappropriate because the long head of the triceps is not the main static restraint that prevents anterior glenohumeral dislocation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acromioclavicular joint cartilage is inappropriate because acromioclavicular joint injury causes pain at the AC joint, not recurrent anterior glenohumeral instability."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Deltoid muscle fibers is inappropriate because deltoid injury can impair shoulder movement, but it is not the usual cause of recurrent traumatic anterior instability."
            },
            {
              "id": "B",
              "text": "Option A: Acromioclavicular joint cartilage is inappropriate because acromioclavicular joint injury causes pain at the AC joint, not recurrent anterior glenohumeral instability."
            },
            {
              "id": "C",
              "text": "Option D: Long head of the triceps tendon is inappropriate because the long head of the triceps is not the main static restraint that prevents anterior glenohumeral dislocation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Deltoid muscle fibers is inappropriate because deltoid injury can impair shoulder movement, but it is not the usual cause of recurrent traumatic anterior instability."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long head of the triceps tendon is inappropriate because the long head of the triceps is not the main static restraint that prevents anterior glenohumeral dislocation."
            },
            {
              "id": "B",
              "text": "Option A: Acromioclavicular joint cartilage is inappropriate because acromioclavicular joint injury causes pain at the AC joint, not recurrent anterior glenohumeral instability."
            },
            {
              "id": "C",
              "text": "Option C: Deltoid muscle fibers is inappropriate because deltoid injury can impair shoulder movement, but it is not the usual cause of recurrent traumatic anterior instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long head of the triceps tendon is inappropriate because the long head of the triceps is not the main static restraint that prevents anterior glenohumeral dislocation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subacromial bursa is inappropriate because subacromial bursitis causes pain syndromes, not repeated traumatic dislocation."
            },
            {
              "id": "B",
              "text": "Option A: Acromioclavicular joint cartilage is inappropriate because acromioclavicular joint injury causes pain at the AC joint, not recurrent anterior glenohumeral instability."
            },
            {
              "id": "C",
              "text": "Option C: Deltoid muscle fibers is inappropriate because deltoid injury can impair shoulder movement, but it is not the usual cause of recurrent traumatic anterior instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subacromial bursa is inappropriate because subacromial bursitis causes pain syndromes, not repeated traumatic dislocation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Supraspinatus tendon insertion is inappropriate because supraspinatus injury may cause pain or weakness but is not the usual substrate for recurrent anterior instability in a young patient."
            },
            {
              "id": "B",
              "text": "Option A: Acromioclavicular joint cartilage is inappropriate because acromioclavicular joint injury causes pain at the AC joint, not recurrent anterior glenohumeral instability."
            },
            {
              "id": "C",
              "text": "Option C: Deltoid muscle fibers is inappropriate because deltoid injury can impair shoulder movement, but it is not the usual cause of recurrent traumatic anterior instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Supraspinatus tendon insertion is inappropriate because supraspinatus injury may cause pain or weakness but is not the usual substrate for recurrent anterior instability in a young patient."
        }
      }
    },
    {
      "externalId": "free137-i073-hcv-risk-factor-significance",
      "expectedHashes": {
        "ranaze_step3_uat": "b998a902373e9033fa55a1555a8d15ee46a25d3bcedd5ab1c3dd27c9cdf7e4be",
        "ranaze_step3_prd": "b998a902373e9033fa55a1555a8d15ee46a25d3bcedd5ab1c3dd27c9cdf7e4be"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "All listed factors were significantly associated with hepatitis C transmission is inappropriate because this is incorrect because several reported confidence intervals include 1 and several p values are above 0.05."
            },
            {
              "id": "B",
              "text": "Option B: Cesarean delivery was the clearest statistically established risk factor is inappropriate because cesarean delivery has an elevated point estimate, but its confidence interval includes 1 and its p value is 0.15, so it is not statistically significant."
            },
            {
              "id": "C",
              "text": "Option C: Clinical chorioamnionitis was the strongest statistically significant association is inappropriate because chorioamnionitis has the largest point estimate, but its confidence interval includes 1 and its p value is 0.08, so it is not statistically significant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "All listed factors were significantly associated with hepatitis C transmission is inappropriate because this is incorrect because several reported confidence intervals include 1 and several p values are above 0.05."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cesarean delivery was the clearest statistically established risk factor is inappropriate because cesarean delivery has an elevated point estimate, but its confidence interval includes 1 and its p value is 0.15, so it is not statistically significant."
            },
            {
              "id": "B",
              "text": "Option A: All listed factors were significantly associated with hepatitis C transmission is inappropriate because this is incorrect because several reported confidence intervals include 1 and several p values are above 0.05."
            },
            {
              "id": "C",
              "text": "Option C: Clinical chorioamnionitis was the strongest statistically significant association is inappropriate because chorioamnionitis has the largest point estimate, but its confidence interval includes 1 and its p value is 0.08, so it is not statistically significant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cesarean delivery was the clearest statistically established risk factor is inappropriate because cesarean delivery has an elevated point estimate, but its confidence interval includes 1 and its p value is 0.15, so it is not statistically significant."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Clinical chorioamnionitis was the strongest statistically significant association is inappropriate because chorioamnionitis has the largest point estimate, but its confidence interval includes 1 and its p value is 0.08, so it is not statistically significant."
            },
            {
              "id": "B",
              "text": "Option A: All listed factors were significantly associated with hepatitis C transmission is inappropriate because this is incorrect because several reported confidence intervals include 1 and several p values are above 0.05."
            },
            {
              "id": "C",
              "text": "Option B: Cesarean delivery was the clearest statistically established risk factor is inappropriate because cesarean delivery has an elevated point estimate, but its confidence interval includes 1 and its p value is 0.15, so it is not statistically significant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Clinical chorioamnionitis was the strongest statistically significant association is inappropriate because chorioamnionitis has the largest point estimate, but its confidence interval includes 1 and its p value is 0.08, so it is not statistically significant."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fetal scalp electrode use was significantly protective against hepatitis C transmission is inappropriate because a risk ratio below 1 suggests possible protection, but this result is not statistically significant because the confidence interval includes 1 and the p value is 0.76."
            },
            {
              "id": "B",
              "text": "Option A: All listed factors were significantly associated with hepatitis C transmission is inappropriate because this is incorrect because several reported confidence intervals include 1 and several p values are above 0.05."
            },
            {
              "id": "C",
              "text": "Option B: Cesarean delivery was the clearest statistically established risk factor is inappropriate because cesarean delivery has an elevated point estimate, but its confidence interval includes 1 and its p value is 0.15, so it is not statistically significant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fetal scalp electrode use was significantly protective against hepatitis C transmission is inappropriate because a risk ratio below 1 suggests possible protection, but this result is not statistically significant because the confidence interval includes 1 and the p value is 0.76."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No studied factor was significantly associated with hepatitis C transmission is inappropriate because this is incorrect because infant HIV infection is significantly associated with hepatitis C transmission in the reported results."
            },
            {
              "id": "B",
              "text": "Option A: All listed factors were significantly associated with hepatitis C transmission is inappropriate because this is incorrect because several reported confidence intervals include 1 and several p values are above 0.05."
            },
            {
              "id": "C",
              "text": "Option B: Cesarean delivery was the clearest statistically established risk factor is inappropriate because cesarean delivery has an elevated point estimate, but its confidence interval includes 1 and its p value is 0.15, so it is not statistically significant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No studied factor was significantly associated with hepatitis C transmission is inappropriate because this is incorrect because infant HIV infection is significantly associated with hepatitis C transmission in the reported results."
        }
      }
    },
    {
      "externalId": "free137-i074-home-hospice-after-refusal",
      "expectedHashes": {
        "ranaze_step3_uat": "4c029b2bdaf3820089a8d4656eb526972b0ef7a3f9d16318f16f4230b7c3ef51",
        "ranaze_step3_prd": "4c029b2bdaf3820089a8d4656eb526972b0ef7a3f9d16318f16f4230b7c3ef51"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange immediate hospital admission for intensive treatment is inappropriate because hospital admission would conflict with this patient\u0027s current stated wishes and her previously documented treatment preferences."
            },
            {
              "id": "B",
              "text": "Option C: Request an emergency ethics committee review is inappropriate because ethics consultation is more appropriate when disagreement or uncertainty remains unresolved; here the patient\u0027s wishes are clear and the daughter now understands the support options."
            },
            {
              "id": "C",
              "text": "Option D: Order home continuous positive airway pressure as the main intervention is inappropriate because home CPAP does not address the broader goal-concordant plan as well as hospice for a patient choosing comfort-focused end-of-life care at home."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange immediate hospital admission for intensive treatment is inappropriate because hospital admission would conflict with this patient\u0027s current stated wishes and her previously documented treatment preferences."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request an emergency ethics committee review is inappropriate because ethics consultation is more appropriate when disagreement or uncertainty remains unresolved; here the patient\u0027s wishes are clear and the daughter now understands the support options."
            },
            {
              "id": "B",
              "text": "Option A: Arrange immediate hospital admission for intensive treatment is inappropriate because hospital admission would conflict with this patient\u0027s current stated wishes and her previously documented treatment preferences."
            },
            {
              "id": "C",
              "text": "Option D: Order home continuous positive airway pressure as the main intervention is inappropriate because home CPAP does not address the broader goal-concordant plan as well as hospice for a patient choosing comfort-focused end-of-life care at home."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request an emergency ethics committee review is inappropriate because ethics consultation is more appropriate when disagreement or uncertainty remains unresolved; here the patient\u0027s wishes are clear and the daughter now understands the support options."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order home continuous positive airway pressure as the main intervention is inappropriate because home CPAP does not address the broader goal-concordant plan as well as hospice for a patient choosing comfort-focused end-of-life care at home."
            },
            {
              "id": "B",
              "text": "Option A: Arrange immediate hospital admission for intensive treatment is inappropriate because hospital admission would conflict with this patient\u0027s current stated wishes and her previously documented treatment preferences."
            },
            {
              "id": "C",
              "text": "Option C: Request an emergency ethics committee review is inappropriate because ethics consultation is more appropriate when disagreement or uncertainty remains unresolved; here the patient\u0027s wishes are clear and the daughter now understands the support options."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order home continuous positive airway pressure as the main intervention is inappropriate because home CPAP does not address the broader goal-concordant plan as well as hospice for a patient choosing comfort-focused end-of-life care at home."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin involuntary psychiatric evaluation is inappropriate because there is no stem evidence requiring involuntary psychiatric evaluation; she answers questions appropriately and expresses a consistent treatment preference."
            },
            {
              "id": "B",
              "text": "Option A: Arrange immediate hospital admission for intensive treatment is inappropriate because hospital admission would conflict with this patient\u0027s current stated wishes and her previously documented treatment preferences."
            },
            {
              "id": "C",
              "text": "Option C: Request an emergency ethics committee review is inappropriate because ethics consultation is more appropriate when disagreement or uncertainty remains unresolved; here the patient\u0027s wishes are clear and the daughter now understands the support options."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin involuntary psychiatric evaluation is inappropriate because there is no stem evidence requiring involuntary psychiatric evaluation; she answers questions appropriately and expresses a consistent treatment preference."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request home suctioning as the primary intervention is inappropriate because suctioning may help selected symptoms, but it is not the best primary next step when the patient needs comprehensive hospice-level support."
            },
            {
              "id": "B",
              "text": "Option A: Arrange immediate hospital admission for intensive treatment is inappropriate because hospital admission would conflict with this patient\u0027s current stated wishes and her previously documented treatment preferences."
            },
            {
              "id": "C",
              "text": "Option C: Request an emergency ethics committee review is inappropriate because ethics consultation is more appropriate when disagreement or uncertainty remains unresolved; here the patient\u0027s wishes are clear and the daughter now understands the support options."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request home suctioning as the primary intervention is inappropriate because suctioning may help selected symptoms, but it is not the best primary next step when the patient needs comprehensive hospice-level support."
        }
      }
    },
    {
      "externalId": "free137-i076-lateral-medullary-horner-sympathetic-underactivity",
      "expectedHashes": {
        "ranaze_step3_uat": "c30513f2cd9f2a80bdace0985a36bb17c0a70ebfce73ad18dab69dbd8544115b",
        "ranaze_step3_prd": "c30513f2cd9f2a80bdace0985a36bb17c0a70ebfce73ad18dab69dbd8544115b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Parasympathetic overactivity is not the primary lesion; the findings reflect loss of sympathetic input."
            },
            {
              "id": "B",
              "text": "Option C: Oculomotor nerve hyperactivity is inappropriate because oculomotor hyperactivity does not produce this crossed brainstem syndrome."
            },
            {
              "id": "C",
              "text": "Option D: Neuromuscular junction blockade is inappropriate because neuromuscular junction disease would not cause crossed sensory loss and ataxia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Parasympathetic overactivity is not the primary lesion; the findings reflect loss of sympathetic input."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oculomotor nerve hyperactivity is inappropriate because oculomotor hyperactivity does not produce this crossed brainstem syndrome."
            },
            {
              "id": "B",
              "text": "Option A: Parasympathetic overactivity is not the primary lesion; the findings reflect loss of sympathetic input."
            },
            {
              "id": "C",
              "text": "Option D: Neuromuscular junction blockade is inappropriate because neuromuscular junction disease would not cause crossed sensory loss and ataxia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oculomotor nerve hyperactivity is inappropriate because oculomotor hyperactivity does not produce this crossed brainstem syndrome."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neuromuscular junction blockade is inappropriate because neuromuscular junction disease would not cause crossed sensory loss and ataxia."
            },
            {
              "id": "B",
              "text": "Option A: Parasympathetic overactivity is not the primary lesion; the findings reflect loss of sympathetic input."
            },
            {
              "id": "C",
              "text": "Option C: Oculomotor nerve hyperactivity is inappropriate because oculomotor hyperactivity does not produce this crossed brainstem syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neuromuscular junction blockade is inappropriate because neuromuscular junction disease would not cause crossed sensory loss and ataxia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Facial nerve denervation is inappropriate because facial nerve injury does not cause miosis."
            },
            {
              "id": "B",
              "text": "Option A: Parasympathetic overactivity is not the primary lesion; the findings reflect loss of sympathetic input."
            },
            {
              "id": "C",
              "text": "Option C: Oculomotor nerve hyperactivity is inappropriate because oculomotor hyperactivity does not produce this crossed brainstem syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Facial nerve denervation is inappropriate because facial nerve injury does not cause miosis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased intraocular pressure does not explain ptosis with crossed sensory deficits."
            },
            {
              "id": "B",
              "text": "Option A: Parasympathetic overactivity is not the primary lesion; the findings reflect loss of sympathetic input."
            },
            {
              "id": "C",
              "text": "Option C: Oculomotor nerve hyperactivity is inappropriate because oculomotor hyperactivity does not produce this crossed brainstem syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased intraocular pressure does not explain ptosis with crossed sensory deficits."
        }
      }
    },
    {
      "externalId": "free137-i081-hiv-anal-condyloma-imiquimod",
      "expectedHashes": {
        "ranaze_step3_uat": "800a03d158ea250aa6e901f34bfb048dd686bf61113d58e502f36833495486b7",
        "ranaze_step3_prd": "800a03d158ea250aa6e901f34bfb048dd686bf61113d58e502f36833495486b7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral acyclovir is inappropriate because acyclovir is used for herpes simplex, which causes vesicles or ulcers rather than verrucous warts."
            },
            {
              "id": "B",
              "text": "Option C: Intramuscular ceftriaxone is inappropriate because ceftriaxone treats gonococcal infection, not HPV warts."
            },
            {
              "id": "C",
              "text": "Option D: Oral metronidazole is inappropriate because metronidazole does not treat condyloma acuminata."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral acyclovir is inappropriate because acyclovir is used for herpes simplex, which causes vesicles or ulcers rather than verrucous warts."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intramuscular ceftriaxone is inappropriate because ceftriaxone treats gonococcal infection, not HPV warts."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpes simplex, which causes vesicles or ulcers rather than verrucous warts."
            },
            {
              "id": "C",
              "text": "Option D: Oral metronidazole is inappropriate because metronidazole does not treat condyloma acuminata."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intramuscular ceftriaxone is inappropriate because ceftriaxone treats gonococcal infection, not HPV warts."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral metronidazole is inappropriate because metronidazole does not treat condyloma acuminata."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpes simplex, which causes vesicles or ulcers rather than verrucous warts."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular ceftriaxone is inappropriate because ceftriaxone treats gonococcal infection, not HPV warts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral metronidazole is inappropriate because metronidazole does not treat condyloma acuminata."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intramuscular benzathine penicillin G is inappropriate because benzathine penicillin G treats syphilis, not HPV warts."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpes simplex, which causes vesicles or ulcers rather than verrucous warts."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular ceftriaxone is inappropriate because ceftriaxone treats gonococcal infection, not HPV warts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intramuscular benzathine penicillin G is inappropriate because benzathine penicillin G treats syphilis, not HPV warts."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical hydrocortisone is inappropriate because hydrocortisone may reduce irritation but does not treat HPV lesions."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpes simplex, which causes vesicles or ulcers rather than verrucous warts."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular ceftriaxone is inappropriate because ceftriaxone treats gonococcal infection, not HPV warts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical hydrocortisone is inappropriate because hydrocortisone may reduce irritation but does not treat HPV lesions."
        }
      }
    },
    {
      "externalId": "free137-i082-physiologic-genu-varum-observation",
      "expectedHashes": {
        "ranaze_step3_uat": "e68a1aa6da25d930bd85e77053754c584d707495defa992b621bd0112b6534d4",
        "ranaze_step3_prd": "e68a1aa6da25d930bd85e77053754c584d707495defa992b621bd0112b6534d4"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate long-leg bracing is inappropriate because bracing is not indicated for classic physiologic genu varum."
            },
            {
              "id": "B",
              "text": "Option B: Vitamin D supplementation is not the best answer without findings suggesting rickets or deficiency."
            },
            {
              "id": "C",
              "text": "Option C: Structured physical therapy is inappropriate because physical therapy does not correct normal physiologic bowing in this setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate long-leg bracing is inappropriate because bracing is not indicated for classic physiologic genu varum."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vitamin D supplementation is not the best answer without findings suggesting rickets or deficiency."
            },
            {
              "id": "B",
              "text": "Option A: Immediate long-leg bracing is inappropriate because bracing is not indicated for classic physiologic genu varum."
            },
            {
              "id": "C",
              "text": "Option C: Structured physical therapy is inappropriate because physical therapy does not correct normal physiologic bowing in this setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vitamin D supplementation is not the best answer without findings suggesting rickets or deficiency."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Structured physical therapy is inappropriate because physical therapy does not correct normal physiologic bowing in this setting."
            },
            {
              "id": "B",
              "text": "Option A: Immediate long-leg bracing is inappropriate because bracing is not indicated for classic physiologic genu varum."
            },
            {
              "id": "C",
              "text": "Option B: Vitamin D supplementation is not the best answer without findings suggesting rickets or deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Structured physical therapy is inappropriate because physical therapy does not correct normal physiologic bowing in this setting."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Corrective osteotomy is inappropriate because surgery is reserved for pathologic or persistent deformity, not mild symmetric bowing in a toddler."
            },
            {
              "id": "B",
              "text": "Option A: Immediate long-leg bracing is inappropriate because bracing is not indicated for classic physiologic genu varum."
            },
            {
              "id": "C",
              "text": "Option B: Vitamin D supplementation is not the best answer without findings suggesting rickets or deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Corrective osteotomy is inappropriate because surgery is reserved for pathologic or persistent deformity, not mild symmetric bowing in a toddler."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bilateral lower-extremity radiographs is inappropriate because routine radiographs are not needed when the presentation is classic for physiologic genu varum."
            },
            {
              "id": "B",
              "text": "Option A: Immediate long-leg bracing is inappropriate because bracing is not indicated for classic physiologic genu varum."
            },
            {
              "id": "C",
              "text": "Option B: Vitamin D supplementation is not the best answer without findings suggesting rickets or deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bilateral lower-extremity radiographs is inappropriate because routine radiographs are not needed when the presentation is classic for physiologic genu varum."
        }
      }
    },
    {
      "externalId": "free137-i083-silicosis-copd-severe-hypoxemia-oxygen",
      "expectedHashes": {
        "ranaze_step3_uat": "f4fe9a90d27afb45c8a0b2177fdf409951a402318d633d87ab99c481286b0c89",
        "ranaze_step3_prd": "f4fe9a90d27afb45c8a0b2177fdf409951a402318d633d87ab99c481286b0c89"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Azathioprine therapy is inappropriate because azathioprine does not address the immediate problem of severe hypoxemia."
            },
            {
              "id": "B",
              "text": "Option B: Urgent bronchoscopy is inappropriate because bronchoscopy is not the priority when the dominant acute issue is profound oxygen desaturation."
            },
            {
              "id": "C",
              "text": "Option D: Nocturnal CPAP therapy is inappropriate because nocturnal CPAP does not treat severe daytime hypoxemia of this degree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Azathioprine therapy is inappropriate because azathioprine does not address the immediate problem of severe hypoxemia."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urgent bronchoscopy is inappropriate because bronchoscopy is not the priority when the dominant acute issue is profound oxygen desaturation."
            },
            {
              "id": "B",
              "text": "Option A: Azathioprine therapy is inappropriate because azathioprine does not address the immediate problem of severe hypoxemia."
            },
            {
              "id": "C",
              "text": "Option D: Nocturnal CPAP therapy is inappropriate because nocturnal CPAP does not treat severe daytime hypoxemia of this degree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urgent bronchoscopy is inappropriate because bronchoscopy is not the priority when the dominant acute issue is profound oxygen desaturation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nocturnal CPAP therapy is inappropriate because nocturnal CPAP does not treat severe daytime hypoxemia of this degree."
            },
            {
              "id": "B",
              "text": "Option A: Azathioprine therapy is inappropriate because azathioprine does not address the immediate problem of severe hypoxemia."
            },
            {
              "id": "C",
              "text": "Option B: Urgent bronchoscopy is inappropriate because bronchoscopy is not the priority when the dominant acute issue is profound oxygen desaturation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nocturnal CPAP therapy is inappropriate because nocturnal CPAP does not treat severe daytime hypoxemia of this degree."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Referral for lung volume reduction surgery is inappropriate because surgical referral is not the immediate next step in an acutely hypoxemic patient."
            },
            {
              "id": "B",
              "text": "Option A: Azathioprine therapy is inappropriate because azathioprine does not address the immediate problem of severe hypoxemia."
            },
            {
              "id": "C",
              "text": "Option B: Urgent bronchoscopy is inappropriate because bronchoscopy is not the priority when the dominant acute issue is profound oxygen desaturation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Referral for lung volume reduction surgery is inappropriate because surgical referral is not the immediate next step in an acutely hypoxemic patient."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whole-lung lavage is not the treatment for this silicosis-associated presentation with profound hypoxemia."
            },
            {
              "id": "B",
              "text": "Option A: Azathioprine therapy is inappropriate because azathioprine does not address the immediate problem of severe hypoxemia."
            },
            {
              "id": "C",
              "text": "Option B: Urgent bronchoscopy is inappropriate because bronchoscopy is not the priority when the dominant acute issue is profound oxygen desaturation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whole-lung lavage is not the treatment for this silicosis-associated presentation with profound hypoxemia."
        }
      }
    },
    {
      "externalId": "free137-i084-severe-hyponatremia-seizure-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "c79e7596b6f6f810c98c4837c54b6e34c5089bc1bad852977a2d1ab0f4a4edac",
        "ranaze_step3_prd": "c79e7596b6f6f810c98c4837c54b6e34c5089bc1bad852977a2d1ab0f4a4edac"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Atrioventricular nodal reentrant tachycardia is inappropriate because severe hyponatremia does not characteristically cause AV nodal reentrant tachycardia."
            },
            {
              "id": "B",
              "text": "Option B: Acute pancreatitis is inappropriate because pancreatitis is not the expected immediate complication of profound hyponatremia."
            },
            {
              "id": "C",
              "text": "Option C: Pulmonary edema is inappropriate because the near-term life-threatening consequence of this presentation is neurologic deterioration from severe hyponatremia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Atrioventricular nodal reentrant tachycardia is inappropriate because severe hyponatremia does not characteristically cause AV nodal reentrant tachycardia."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute pancreatitis is inappropriate because pancreatitis is not the expected immediate complication of profound hyponatremia."
            },
            {
              "id": "B",
              "text": "Option A: Atrioventricular nodal reentrant tachycardia is inappropriate because severe hyponatremia does not characteristically cause AV nodal reentrant tachycardia."
            },
            {
              "id": "C",
              "text": "Option C: Pulmonary edema is inappropriate because the near-term life-threatening consequence of this presentation is neurologic deterioration from severe hyponatremia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute pancreatitis is inappropriate because pancreatitis is not the expected immediate complication of profound hyponatremia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary edema is inappropriate because the near-term life-threatening consequence of this presentation is neurologic deterioration from severe hyponatremia."
            },
            {
              "id": "B",
              "text": "Option A: Atrioventricular nodal reentrant tachycardia is inappropriate because severe hyponatremia does not characteristically cause AV nodal reentrant tachycardia."
            },
            {
              "id": "C",
              "text": "Option B: Acute pancreatitis is inappropriate because pancreatitis is not the expected immediate complication of profound hyponatremia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary edema is inappropriate because the near-term life-threatening consequence of this presentation is neurologic deterioration from severe hyponatremia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Torsades de pointes is associated with QT prolongation, which is not present here."
            },
            {
              "id": "B",
              "text": "Option A: Atrioventricular nodal reentrant tachycardia is inappropriate because severe hyponatremia does not characteristically cause AV nodal reentrant tachycardia."
            },
            {
              "id": "C",
              "text": "Option B: Acute pancreatitis is inappropriate because pancreatitis is not the expected immediate complication of profound hyponatremia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Torsades de pointes is associated with QT prolongation, which is not present here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Massive gastrointestinal hemorrhage is inappropriate because nSAID exposure may increase bleeding risk, but the most immediate danger from sodium 104 mEq/L is seizure from severe hyponatremia."
            },
            {
              "id": "B",
              "text": "Option A: Atrioventricular nodal reentrant tachycardia is inappropriate because severe hyponatremia does not characteristically cause AV nodal reentrant tachycardia."
            },
            {
              "id": "C",
              "text": "Option B: Acute pancreatitis is inappropriate because pancreatitis is not the expected immediate complication of profound hyponatremia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Massive gastrointestinal hemorrhage is inappropriate because nSAID exposure may increase bleeding risk, but the most immediate danger from sodium 104 mEq/L is seizure from severe hyponatremia."
        }
      }
    },
    {
      "externalId": "free137-i085-suspicious-thyroid-nodule-fna",
      "expectedHashes": {
        "ranaze_step3_uat": "a7301ba534763b495387753a879193be89e1f34c34aeb115a2339a4680d7a6cc",
        "ranaze_step3_prd": "a7301ba534763b495387753a879193be89e1f34c34aeb115a2339a4680d7a6cc"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat ultrasonography in 12 months without tissue sampling is inappropriate because surveillance alone is not appropriate for a suspicious nodule of this size."
            },
            {
              "id": "B",
              "text": "Option C: Radionuclide thyroid scan is inappropriate because radionuclide scanning is mainly used when the TSH is low."
            },
            {
              "id": "C",
              "text": "Option D: Contrast-enhanced CT of the neck is inappropriate because cT is not the next diagnostic step for a thyroid nodule already well characterized by ultrasonography."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat ultrasonography in 12 months without tissue sampling is inappropriate because surveillance alone is not appropriate for a suspicious nodule of this size."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radionuclide thyroid scan is inappropriate because radionuclide scanning is mainly used when the TSH is low."
            },
            {
              "id": "B",
              "text": "Option A: Repeat ultrasonography in 12 months without tissue sampling is inappropriate because surveillance alone is not appropriate for a suspicious nodule of this size."
            },
            {
              "id": "C",
              "text": "Option D: Contrast-enhanced CT of the neck is inappropriate because cT is not the next diagnostic step for a thyroid nodule already well characterized by ultrasonography."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radionuclide thyroid scan is inappropriate because radionuclide scanning is mainly used when the TSH is low."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contrast-enhanced CT of the neck is inappropriate because cT is not the next diagnostic step for a thyroid nodule already well characterized by ultrasonography."
            },
            {
              "id": "B",
              "text": "Option A: Repeat ultrasonography in 12 months without tissue sampling is inappropriate because surveillance alone is not appropriate for a suspicious nodule of this size."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide thyroid scan is inappropriate because radionuclide scanning is mainly used when the TSH is low."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contrast-enhanced CT of the neck is inappropriate because cT is not the next diagnostic step for a thyroid nodule already well characterized by ultrasonography."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diagnostic hemithyroidectomy is inappropriate because surgery is not the usual first diagnostic step before cytologic sampling in this setting."
            },
            {
              "id": "B",
              "text": "Option A: Repeat ultrasonography in 12 months without tissue sampling is inappropriate because surveillance alone is not appropriate for a suspicious nodule of this size."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide thyroid scan is inappropriate because radionuclide scanning is mainly used when the TSH is low."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diagnostic hemithyroidectomy is inappropriate because surgery is not the usual first diagnostic step before cytologic sampling in this setting."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation without further evaluation is inappropriate because a suspicious thyroid nodule should not be left without further evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Repeat ultrasonography in 12 months without tissue sampling is inappropriate because surveillance alone is not appropriate for a suspicious nodule of this size."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide thyroid scan is inappropriate because radionuclide scanning is mainly used when the TSH is low."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation without further evaluation is inappropriate because a suspicious thyroid nodule should not be left without further evaluation."
        }
      }
    },
    {
      "externalId": "free137-i086-unstable-wide-complex-tachycardia",
      "expectedHashes": {
        "ranaze_step3_uat": "2f5e0444fb67f6f41cdd47fbc1d6122760fa983b8d0cc8460ac8e1cb4bffbfd0",
        "ranaze_step3_prd": "2f5e0444fb67f6f41cdd47fbc1d6122760fa983b8d0cc8460ac8e1cb4bffbfd0"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous adenosine is inappropriate because adenosine may be considered in selected stable regular monomorphic tachycardias, but it is not the correct first step in a profoundly unstable patient."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous amiodarone infusion is inappropriate because amiodarone can be used for some stable wide-complex tachyarrhythmias, but this patient\u0027s instability requires immediate electricity first."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous diltiazem is inappropriate because diltiazem is inappropriate for presumed ventricular tachycardia and would be dangerous in a hypotensive unstable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous adenosine is inappropriate because adenosine may be considered in selected stable regular monomorphic tachycardias, but it is not the correct first step in a profoundly unstable patient."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous amiodarone infusion is inappropriate because amiodarone can be used for some stable wide-complex tachyarrhythmias, but this patient\u0027s instability requires immediate electricity first."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous adenosine is inappropriate because adenosine may be considered in selected stable regular monomorphic tachycardias, but it is not the correct first step in a profoundly unstable patient."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous diltiazem is inappropriate because diltiazem is inappropriate for presumed ventricular tachycardia and would be dangerous in a hypotensive unstable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous amiodarone infusion is inappropriate because amiodarone can be used for some stable wide-complex tachyarrhythmias, but this patient\u0027s instability requires immediate electricity first."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous diltiazem is inappropriate because diltiazem is inappropriate for presumed ventricular tachycardia and would be dangerous in a hypotensive unstable patient."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous adenosine is inappropriate because adenosine may be considered in selected stable regular monomorphic tachycardias, but it is not the correct first step in a profoundly unstable patient."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous amiodarone infusion is inappropriate because amiodarone can be used for some stable wide-complex tachyarrhythmias, but this patient\u0027s instability requires immediate electricity first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous diltiazem is inappropriate because diltiazem is inappropriate for presumed ventricular tachycardia and would be dangerous in a hypotensive unstable patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe while awaiting cardiology consultation is inappropriate because specialty consultation should not delay emergent treatment of hemodynamically unstable tachyarrhythmia."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous adenosine is inappropriate because adenosine may be considered in selected stable regular monomorphic tachycardias, but it is not the correct first step in a profoundly unstable patient."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous amiodarone infusion is inappropriate because amiodarone can be used for some stable wide-complex tachyarrhythmias, but this patient\u0027s instability requires immediate electricity first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe while awaiting cardiology consultation is inappropriate because specialty consultation should not delay emergent treatment of hemodynamically unstable tachyarrhythmia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform unsynchronized defibrillation is inappropriate because unsynchronized defibrillation is used for pulseless ventricular tachycardia, ventricular fibrillation, or polymorphic VT, not organized unstable tachycardia with a pulse."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous adenosine is inappropriate because adenosine may be considered in selected stable regular monomorphic tachycardias, but it is not the correct first step in a profoundly unstable patient."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous amiodarone infusion is inappropriate because amiodarone can be used for some stable wide-complex tachyarrhythmias, but this patient\u0027s instability requires immediate electricity first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform unsynchronized defibrillation is inappropriate because unsynchronized defibrillation is used for pulseless ventricular tachycardia, ventricular fibrillation, or polymorphic VT, not organized unstable tachycardia with a pulse."
        }
      }
    },
    {
      "externalId": "free137-i087-uncomplicated-varicose-veins-compression",
      "expectedHashes": {
        "ranaze_step3_uat": "fd4c3af2ef6a3566b7aba526a10144d47220e5c3bd00ba396de808d5d2245afb",
        "ranaze_step3_prd": "fd4c3af2ef6a3566b7aba526a10144d47220e5c3bd00ba396de808d5d2245afb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Therapeutic anticoagulation is inappropriate because anticoagulation is not indicated without venous thrombosis."
            },
            {
              "id": "B",
              "text": "Option C: Urgent endovenous ablation is inappropriate because ablation may be considered for persistent symptoms after vascular assessment but is not urgent."
            },
            {
              "id": "C",
              "text": "Option D: Long-term loop diuretic therapy is inappropriate because diuretics do not correct superficial venous reflux."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Therapeutic anticoagulation is inappropriate because anticoagulation is not indicated without venous thrombosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urgent endovenous ablation is inappropriate because ablation may be considered for persistent symptoms after vascular assessment but is not urgent."
            },
            {
              "id": "B",
              "text": "Option B: Therapeutic anticoagulation is inappropriate because anticoagulation is not indicated without venous thrombosis."
            },
            {
              "id": "C",
              "text": "Option D: Long-term loop diuretic therapy is inappropriate because diuretics do not correct superficial venous reflux."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urgent endovenous ablation is inappropriate because ablation may be considered for persistent symptoms after vascular assessment but is not urgent."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long-term loop diuretic therapy is inappropriate because diuretics do not correct superficial venous reflux."
            },
            {
              "id": "B",
              "text": "Option B: Therapeutic anticoagulation is inappropriate because anticoagulation is not indicated without venous thrombosis."
            },
            {
              "id": "C",
              "text": "Option C: Urgent endovenous ablation is inappropriate because ablation may be considered for persistent symptoms after vascular assessment but is not urgent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long-term loop diuretic therapy is inappropriate because diuretics do not correct superficial venous reflux."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inferior vena cava filter placement is inappropriate because an IVC filter is reserved for selected venous thromboembolism cases."
            },
            {
              "id": "B",
              "text": "Option B: Therapeutic anticoagulation is inappropriate because anticoagulation is not indicated without venous thrombosis."
            },
            {
              "id": "C",
              "text": "Option C: Urgent endovenous ablation is inappropriate because ablation may be considered for persistent symptoms after vascular assessment but is not urgent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inferior vena cava filter placement is inappropriate because an IVC filter is reserved for selected venous thromboembolism cases."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bed rest with avoidance of walking is inappropriate because walking supports calf-muscle pump function and should not be prohibited."
            },
            {
              "id": "B",
              "text": "Option B: Therapeutic anticoagulation is inappropriate because anticoagulation is not indicated without venous thrombosis."
            },
            {
              "id": "C",
              "text": "Option C: Urgent endovenous ablation is inappropriate because ablation may be considered for persistent symptoms after vascular assessment but is not urgent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bed rest with avoidance of walking is inappropriate because walking supports calf-muscle pump function and should not be prohibited."
        }
      }
    },
    {
      "externalId": "free137-i090-papilledema-new-headache-neuroimaging",
      "expectedHashes": {
        "ranaze_step3_uat": "06a7dbd7744ac3eb35856357178b7b3bad577e43102691d4e3c15da27374897f",
        "ranaze_step3_prd": "06a7dbd7744ac3eb35856357178b7b3bad577e43102691d4e3c15da27374897f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start propranolol for presumed migraine prophylaxis is inappropriate because migraine prophylaxis is inappropriate before evaluating red-flag findings such as papilledema and headache worse with Valsalva and on awakening."
            },
            {
              "id": "B",
              "text": "Option C: Order an outpatient electroencephalogram is inappropriate because eEG is not the appropriate test for a headache syndrome with papilledema."
            },
            {
              "id": "C",
              "text": "Option D: Perform lumbar puncture in the office before imaging is inappropriate because lumbar puncture should not precede imaging when elevated intracranial pressure from a mass lesion has not been excluded."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start propranolol for presumed migraine prophylaxis is inappropriate because migraine prophylaxis is inappropriate before evaluating red-flag findings such as papilledema and headache worse with Valsalva and on awakening."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order an outpatient electroencephalogram is inappropriate because eEG is not the appropriate test for a headache syndrome with papilledema."
            },
            {
              "id": "B",
              "text": "Option A: Start propranolol for presumed migraine prophylaxis is inappropriate because migraine prophylaxis is inappropriate before evaluating red-flag findings such as papilledema and headache worse with Valsalva and on awakening."
            },
            {
              "id": "C",
              "text": "Option D: Perform lumbar puncture in the office before imaging is inappropriate because lumbar puncture should not precede imaging when elevated intracranial pressure from a mass lesion has not been excluded."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order an outpatient electroencephalogram is inappropriate because eEG is not the appropriate test for a headache syndrome with papilledema."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform lumbar puncture in the office before imaging is inappropriate because lumbar puncture should not precede imaging when elevated intracranial pressure from a mass lesion has not been excluded."
            },
            {
              "id": "B",
              "text": "Option A: Start propranolol for presumed migraine prophylaxis is inappropriate because migraine prophylaxis is inappropriate before evaluating red-flag findings such as papilledema and headache worse with Valsalva and on awakening."
            },
            {
              "id": "C",
              "text": "Option C: Order an outpatient electroencephalogram is inappropriate because eEG is not the appropriate test for a headache syndrome with papilledema."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform lumbar puncture in the office before imaging is inappropriate because lumbar puncture should not precede imaging when elevated intracranial pressure from a mass lesion has not been excluded."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer routinely to neurology without additional workup is inappropriate because routine referral alone is insufficient because this presentation requires urgent evaluation now."
            },
            {
              "id": "B",
              "text": "Option A: Start propranolol for presumed migraine prophylaxis is inappropriate because migraine prophylaxis is inappropriate before evaluating red-flag findings such as papilledema and headache worse with Valsalva and on awakening."
            },
            {
              "id": "C",
              "text": "Option C: Order an outpatient electroencephalogram is inappropriate because eEG is not the appropriate test for a headache syndrome with papilledema."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer routinely to neurology without additional workup is inappropriate because routine referral alone is insufficient because this presentation requires urgent evaluation now."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassure him that this is most consistent with tension-type headache is inappropriate because reassurance is inappropriate because the new stem includes clear alarm features inconsistent with benign tension-type headache."
            },
            {
              "id": "B",
              "text": "Option A: Start propranolol for presumed migraine prophylaxis is inappropriate because migraine prophylaxis is inappropriate before evaluating red-flag findings such as papilledema and headache worse with Valsalva and on awakening."
            },
            {
              "id": "C",
              "text": "Option C: Order an outpatient electroencephalogram is inappropriate because eEG is not the appropriate test for a headache syndrome with papilledema."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassure him that this is most consistent with tension-type headache is inappropriate because reassurance is inappropriate because the new stem includes clear alarm features inconsistent with benign tension-type headache."
        }
      }
    },
    {
      "externalId": "free137-i096-gastric-coin-observation",
      "expectedHashes": {
        "ranaze_step3_uat": "80393d02669c5f34901dd523fa1a284ebc3a13f70e3a35ddfdfed73dfba5be71",
        "ranaze_step3_prd": "80393d02669c5f34901dd523fa1a284ebc3a13f70e3a35ddfdfed73dfba5be71"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urgent endoscopic retrieval is inappropriate because urgent endoscopy is generally reserved for esophageal coins, symptoms, or failure of a retained gastric object to progress."
            },
            {
              "id": "B",
              "text": "Option B: Whole-bowel irrigation is unnecessary for a single small blunt object."
            },
            {
              "id": "C",
              "text": "Option C: Laparoscopic gastrotomy is inappropriate because surgery is not indicated without obstruction, perforation, or failure of less invasive management."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urgent endoscopic retrieval is inappropriate because urgent endoscopy is generally reserved for esophageal coins, symptoms, or failure of a retained gastric object to progress."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whole-bowel irrigation is unnecessary for a single small blunt object."
            },
            {
              "id": "B",
              "text": "Option A: Urgent endoscopic retrieval is inappropriate because urgent endoscopy is generally reserved for esophageal coins, symptoms, or failure of a retained gastric object to progress."
            },
            {
              "id": "C",
              "text": "Option C: Laparoscopic gastrotomy is inappropriate because surgery is not indicated without obstruction, perforation, or failure of less invasive management."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whole-bowel irrigation is unnecessary for a single small blunt object."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Laparoscopic gastrotomy is inappropriate because surgery is not indicated without obstruction, perforation, or failure of less invasive management."
            },
            {
              "id": "B",
              "text": "Option A: Urgent endoscopic retrieval is inappropriate because urgent endoscopy is generally reserved for esophageal coins, symptoms, or failure of a retained gastric object to progress."
            },
            {
              "id": "C",
              "text": "Option B: Whole-bowel irrigation is unnecessary for a single small blunt object."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Laparoscopic gastrotomy is inappropriate because surgery is not indicated without obstruction, perforation, or failure of less invasive management."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Induce vomiting is inappropriate because induced emesis risks aspiration and is not recommended."
            },
            {
              "id": "B",
              "text": "Option A: Urgent endoscopic retrieval is inappropriate because urgent endoscopy is generally reserved for esophageal coins, symptoms, or failure of a retained gastric object to progress."
            },
            {
              "id": "C",
              "text": "Option B: Whole-bowel irrigation is unnecessary for a single small blunt object."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Induce vomiting is inappropriate because induced emesis risks aspiration and is not recommended."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer activated charcoal is inappropriate because activated charcoal does not bind or remove coins."
            },
            {
              "id": "B",
              "text": "Option A: Urgent endoscopic retrieval is inappropriate because urgent endoscopy is generally reserved for esophageal coins, symptoms, or failure of a retained gastric object to progress."
            },
            {
              "id": "C",
              "text": "Option B: Whole-bowel irrigation is unnecessary for a single small blunt object."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer activated charcoal is inappropriate because activated charcoal does not bind or remove coins."
        }
      }
    },
    {
      "externalId": "free137-i100-copd-auto-peep-ventilator-adjustment",
      "expectedHashes": {
        "ranaze_step3_uat": "51eb18f26291bffdcbda783c33b6ce87ec09e58a020ba820f13b054199d533f6",
        "ranaze_step3_prd": "51eb18f26291bffdcbda783c33b6ce87ec09e58a020ba820f13b054199d533f6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Insert bilateral thoracostomy tubes is inappropriate because bilateral chest tubes are not indicated with a midline trachea and bilateral breath sounds."
            },
            {
              "id": "B",
              "text": "Option B: Increase the respiratory rate is inappropriate because a higher respiratory rate further shortens expiration and worsens air trapping."
            },
            {
              "id": "C",
              "text": "Option D: Administer therapeutic heparin is inappropriate because pulmonary embolism does not explain expiration extending into the next breath immediately after intubation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Insert bilateral thoracostomy tubes is inappropriate because bilateral chest tubes are not indicated with a midline trachea and bilateral breath sounds."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase the respiratory rate is inappropriate because a higher respiratory rate further shortens expiration and worsens air trapping."
            },
            {
              "id": "B",
              "text": "Option A: Insert bilateral thoracostomy tubes is inappropriate because bilateral chest tubes are not indicated with a midline trachea and bilateral breath sounds."
            },
            {
              "id": "C",
              "text": "Option D: Administer therapeutic heparin is inappropriate because pulmonary embolism does not explain expiration extending into the next breath immediately after intubation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase the respiratory rate is inappropriate because a higher respiratory rate further shortens expiration and worsens air trapping."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer therapeutic heparin is inappropriate because pulmonary embolism does not explain expiration extending into the next breath immediately after intubation."
            },
            {
              "id": "B",
              "text": "Option A: Insert bilateral thoracostomy tubes is inappropriate because bilateral chest tubes are not indicated with a midline trachea and bilateral breath sounds."
            },
            {
              "id": "C",
              "text": "Option B: Increase the respiratory rate is inappropriate because a higher respiratory rate further shortens expiration and worsens air trapping."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer therapeutic heparin is inappropriate because pulmonary embolism does not explain expiration extending into the next breath immediately after intubation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give a large crystalloid bolus without changing ventilation is inappropriate because fluid alone does not relieve obstructive dynamic hyperinflation."
            },
            {
              "id": "B",
              "text": "Option A: Insert bilateral thoracostomy tubes is inappropriate because bilateral chest tubes are not indicated with a midline trachea and bilateral breath sounds."
            },
            {
              "id": "C",
              "text": "Option B: Increase the respiratory rate is inappropriate because a higher respiratory rate further shortens expiration and worsens air trapping."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give a large crystalloid bolus without changing ventilation is inappropriate because fluid alone does not relieve obstructive dynamic hyperinflation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start dopamine while maintaining current settings is inappropriate because a vasopressor does not correct the excessive intrathoracic pressure causing shock."
            },
            {
              "id": "B",
              "text": "Option A: Insert bilateral thoracostomy tubes is inappropriate because bilateral chest tubes are not indicated with a midline trachea and bilateral breath sounds."
            },
            {
              "id": "C",
              "text": "Option B: Increase the respiratory rate is inappropriate because a higher respiratory rate further shortens expiration and worsens air trapping."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start dopamine while maintaining current settings is inappropriate because a vasopressor does not correct the excessive intrathoracic pressure causing shock."
        }
      }
    },
    {
      "externalId": "free137-i102-hyperkalemia-ecg-intravenous-calcium",
      "expectedHashes": {
        "ranaze_step3_uat": "a97a38fd855570e3a0c63473a6ef8a42c2264bac536ea6d204aca75bc7e1f881",
        "ranaze_step3_prd": "a97a38fd855570e3a0c63473a6ef8a42c2264bac536ea6d204aca75bc7e1f881"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral sodium zirconium cyclosilicate is inappropriate because a potassium binder acts too slowly to provide immediate cardiac protection."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous furosemide alone is inappropriate because diuresis may remove potassium but does not immediately stabilize the myocardium."
            },
            {
              "id": "C",
              "text": "Option D: Repeat serum potassium in 2 hours is inappropriate because treatment should not be delayed when hyperkalemic ECG changes are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral sodium zirconium cyclosilicate is inappropriate because a potassium binder acts too slowly to provide immediate cardiac protection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous furosemide alone is inappropriate because diuresis may remove potassium but does not immediately stabilize the myocardium."
            },
            {
              "id": "B",
              "text": "Option B: Oral sodium zirconium cyclosilicate is inappropriate because a potassium binder acts too slowly to provide immediate cardiac protection."
            },
            {
              "id": "C",
              "text": "Option D: Repeat serum potassium in 2 hours is inappropriate because treatment should not be delayed when hyperkalemic ECG changes are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous furosemide alone is inappropriate because diuresis may remove potassium but does not immediately stabilize the myocardium."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat serum potassium in 2 hours is inappropriate because treatment should not be delayed when hyperkalemic ECG changes are present."
            },
            {
              "id": "B",
              "text": "Option B: Oral sodium zirconium cyclosilicate is inappropriate because a potassium binder acts too slowly to provide immediate cardiac protection."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous furosemide alone is inappropriate because diuresis may remove potassium but does not immediately stabilize the myocardium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat serum potassium in 2 hours is inappropriate because treatment should not be delayed when hyperkalemic ECG changes are present."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restrict dietary potassium is inappropriate because dietary restriction has no role in immediate life-threatening hyperkalemia."
            },
            {
              "id": "B",
              "text": "Option B: Oral sodium zirconium cyclosilicate is inappropriate because a potassium binder acts too slowly to provide immediate cardiac protection."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous furosemide alone is inappropriate because diuresis may remove potassium but does not immediately stabilize the myocardium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restrict dietary potassium is inappropriate because dietary restriction has no role in immediate life-threatening hyperkalemia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hemodialysis before any medication is inappropriate because dialysis may be needed for refractory hyperkalemia, but calcium should be given immediately first."
            },
            {
              "id": "B",
              "text": "Option B: Oral sodium zirconium cyclosilicate is inappropriate because a potassium binder acts too slowly to provide immediate cardiac protection."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous furosemide alone is inappropriate because diuresis may remove potassium but does not immediately stabilize the myocardium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hemodialysis before any medication is inappropriate because dialysis may be needed for refractory hyperkalemia, but calcium should be given immediately first."
        }
      }
    },
    {
      "externalId": "free137-i104-sickle-aplastic-crisis-prbc-transfusion",
      "expectedHashes": {
        "ranaze_step3_uat": "9d1abebb32ec1486079e6bc3ef22e48e1739faa8fae0225a69f45c5cda15952a",
        "ranaze_step3_prd": "9d1abebb32ec1486079e6bc3ef22e48e1739faa8fae0225a69f45c5cda15952a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase hydroxyurea is inappropriate because hydroxyurea does not rapidly correct life-threatening anemia and may worsen cytopenias."
            },
            {
              "id": "B",
              "text": "Option B: Administer oral iron only is inappropriate because iron alone is too slow and may not address the reticulocytopenia."
            },
            {
              "id": "C",
              "text": "Option C: Begin erythropoietin is inappropriate because erythropoietin is not the immediate treatment for this severe acute anemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase hydroxyurea is inappropriate because hydroxyurea does not rapidly correct life-threatening anemia and may worsen cytopenias."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer oral iron only is inappropriate because iron alone is too slow and may not address the reticulocytopenia."
            },
            {
              "id": "B",
              "text": "Option A: Increase hydroxyurea is inappropriate because hydroxyurea does not rapidly correct life-threatening anemia and may worsen cytopenias."
            },
            {
              "id": "C",
              "text": "Option C: Begin erythropoietin is inappropriate because erythropoietin is not the immediate treatment for this severe acute anemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer oral iron only is inappropriate because iron alone is too slow and may not address the reticulocytopenia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin erythropoietin is inappropriate because erythropoietin is not the immediate treatment for this severe acute anemia."
            },
            {
              "id": "B",
              "text": "Option A: Increase hydroxyurea is inappropriate because hydroxyurea does not rapidly correct life-threatening anemia and may worsen cytopenias."
            },
            {
              "id": "C",
              "text": "Option B: Administer oral iron only is inappropriate because iron alone is too slow and may not address the reticulocytopenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin erythropoietin is inappropriate because erythropoietin is not the immediate treatment for this severe acute anemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform exchange transfusion is inappropriate because exchange transfusion is unnecessary without stroke, severe acute chest syndrome, or another indication to rapidly lower HbS."
            },
            {
              "id": "B",
              "text": "Option A: Increase hydroxyurea is inappropriate because hydroxyurea does not rapidly correct life-threatening anemia and may worsen cytopenias."
            },
            {
              "id": "C",
              "text": "Option B: Administer oral iron only is inappropriate because iron alone is too slow and may not address the reticulocytopenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform exchange transfusion is inappropriate because exchange transfusion is unnecessary without stroke, severe acute chest syndrome, or another indication to rapidly lower HbS."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer desmopressin is inappropriate because desmopressin does not treat uterine blood loss with severe hypoproliferative anemia."
            },
            {
              "id": "B",
              "text": "Option A: Increase hydroxyurea is inappropriate because hydroxyurea does not rapidly correct life-threatening anemia and may worsen cytopenias."
            },
            {
              "id": "C",
              "text": "Option B: Administer oral iron only is inappropriate because iron alone is too slow and may not address the reticulocytopenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer desmopressin is inappropriate because desmopressin does not treat uterine blood loss with severe hypoproliferative anemia."
        }
      }
    },
    {
      "externalId": "free137-i106-atrial-fibrillation-repeat-beta-blocker-rate-control",
      "expectedHashes": {
        "ranaze_step3_uat": "84898fa0a50444fcbd7cb2448b8302ddf18e206c9fc53051c3de56c03a9851af",
        "ranaze_step3_prd": "84898fa0a50444fcbd7cb2448b8302ddf18e206c9fc53051c3de56c03a9851af"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Adenosine may transiently slow AV conduction but does not terminate atrial fibrillation or provide sustained rate control."
            },
            {
              "id": "B",
              "text": "Option B: Digoxin as the sole rapid intervention is inappropriate because digoxin has a slow onset and is less effective during high sympathetic tone."
            },
            {
              "id": "C",
              "text": "Option C: Enalaprilat does not control AV nodal conduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Adenosine may transiently slow AV conduction but does not terminate atrial fibrillation or provide sustained rate control."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Digoxin as the sole rapid intervention is inappropriate because digoxin has a slow onset and is less effective during high sympathetic tone."
            },
            {
              "id": "B",
              "text": "Option A: Adenosine may transiently slow AV conduction but does not terminate atrial fibrillation or provide sustained rate control."
            },
            {
              "id": "C",
              "text": "Option C: Enalaprilat does not control AV nodal conduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Digoxin as the sole rapid intervention is inappropriate because digoxin has a slow onset and is less effective during high sympathetic tone."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Enalaprilat does not control AV nodal conduction."
            },
            {
              "id": "B",
              "text": "Option A: Adenosine may transiently slow AV conduction but does not terminate atrial fibrillation or provide sustained rate control."
            },
            {
              "id": "C",
              "text": "Option B: Digoxin as the sole rapid intervention is inappropriate because digoxin has a slow onset and is less effective during high sympathetic tone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Enalaprilat does not control AV nodal conduction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lidocaine treats ventricular arrhythmias, not atrial fibrillation rate."
            },
            {
              "id": "B",
              "text": "Option A: Adenosine may transiently slow AV conduction but does not terminate atrial fibrillation or provide sustained rate control."
            },
            {
              "id": "C",
              "text": "Option B: Digoxin as the sole rapid intervention is inappropriate because digoxin has a slow onset and is less effective during high sympathetic tone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lidocaine treats ventricular arrhythmias, not atrial fibrillation rate."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Epinephrine would increase ventricular rate."
            },
            {
              "id": "B",
              "text": "Option A: Adenosine may transiently slow AV conduction but does not terminate atrial fibrillation or provide sustained rate control."
            },
            {
              "id": "C",
              "text": "Option B: Digoxin as the sole rapid intervention is inappropriate because digoxin has a slow onset and is less effective during high sympathetic tone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Epinephrine would increase ventricular rate."
        }
      }
    },
    {
      "externalId": "free137-i107-anthracycline-survivor-echocardiography",
      "expectedHashes": {
        "ranaze_step3_uat": "84cd9b92cc837d1f37f094e7d7a017cd2d958f6c586cafb1e64e8ffa0adabcd8",
        "ranaze_step3_prd": "84cd9b92cc837d1f37f094e7d7a017cd2d958f6c586cafb1e64e8ffa0adabcd8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Annual bone marrow biopsy is inappropriate because bone marrow biopsy is not routine surveillance in an asymptomatic lymphoma survivor."
            },
            {
              "id": "B",
              "text": "Option B: Serial CT of the chest every year is inappropriate because routine annual CT causes radiation exposure and is not indicated without recurrence symptoms."
            },
            {
              "id": "C",
              "text": "Option D: Annual thyroid fine-needle aspiration is inappropriate because thyroid screening uses examination and laboratory testing; biopsy is reserved for a nodule."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Annual bone marrow biopsy is inappropriate because bone marrow biopsy is not routine surveillance in an asymptomatic lymphoma survivor."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serial CT of the chest every year is inappropriate because routine annual CT causes radiation exposure and is not indicated without recurrence symptoms."
            },
            {
              "id": "B",
              "text": "Option A: Annual bone marrow biopsy is inappropriate because bone marrow biopsy is not routine surveillance in an asymptomatic lymphoma survivor."
            },
            {
              "id": "C",
              "text": "Option D: Annual thyroid fine-needle aspiration is inappropriate because thyroid screening uses examination and laboratory testing; biopsy is reserved for a nodule."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serial CT of the chest every year is inappropriate because routine annual CT causes radiation exposure and is not indicated without recurrence symptoms."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Annual thyroid fine-needle aspiration is inappropriate because thyroid screening uses examination and laboratory testing; biopsy is reserved for a nodule."
            },
            {
              "id": "B",
              "text": "Option A: Annual bone marrow biopsy is inappropriate because bone marrow biopsy is not routine surveillance in an asymptomatic lymphoma survivor."
            },
            {
              "id": "C",
              "text": "Option B: Serial CT of the chest every year is inappropriate because routine annual CT causes radiation exposure and is not indicated without recurrence symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Annual thyroid fine-needle aspiration is inappropriate because thyroid screening uses examination and laboratory testing; biopsy is reserved for a nodule."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine nerve conduction testing is inappropriate because nerve conduction testing is symptom-driven."
            },
            {
              "id": "B",
              "text": "Option A: Annual bone marrow biopsy is inappropriate because bone marrow biopsy is not routine surveillance in an asymptomatic lymphoma survivor."
            },
            {
              "id": "C",
              "text": "Option B: Serial CT of the chest every year is inappropriate because routine annual CT causes radiation exposure and is not indicated without recurrence symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine nerve conduction testing is inappropriate because nerve conduction testing is symptom-driven."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Monthly serum troponin is inappropriate because monthly troponin testing is not established long-term surveillance."
            },
            {
              "id": "B",
              "text": "Option A: Annual bone marrow biopsy is inappropriate because bone marrow biopsy is not routine surveillance in an asymptomatic lymphoma survivor."
            },
            {
              "id": "C",
              "text": "Option B: Serial CT of the chest every year is inappropriate because routine annual CT causes radiation exposure and is not indicated without recurrence symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Monthly serum troponin is inappropriate because monthly troponin testing is not established long-term surveillance."
        }
      }
    },
    {
      "externalId": "free137-i108-persistent-pica-behavioral-referral",
      "expectedHashes": {
        "ranaze_step3_uat": "19391bad2a07f1b66f7d50ed624e8979c457d2440b5108043420fff9fa47cb67",
        "ranaze_step3_prd": "19391bad2a07f1b66f7d50ed624e8979c457d2440b5108043420fff9fa47cb67"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin fluoxetine is inappropriate because an SSRI is not first-line treatment for isolated pica without a defined comorbid disorder."
            },
            {
              "id": "B",
              "text": "Option B: Begin methylphenidate is inappropriate because a stimulant is not indicated without evidence of ADHD."
            },
            {
              "id": "C",
              "text": "Option C: Begin risperidone is inappropriate because an antipsychotic is not indicated without psychosis or severe behavior requiring such therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin fluoxetine is inappropriate because an SSRI is not first-line treatment for isolated pica without a defined comorbid disorder."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin methylphenidate is inappropriate because a stimulant is not indicated without evidence of ADHD."
            },
            {
              "id": "B",
              "text": "Option A: Begin fluoxetine is inappropriate because an SSRI is not first-line treatment for isolated pica without a defined comorbid disorder."
            },
            {
              "id": "C",
              "text": "Option C: Begin risperidone is inappropriate because an antipsychotic is not indicated without psychosis or severe behavior requiring such therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin methylphenidate is inappropriate because a stimulant is not indicated without evidence of ADHD."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin risperidone is inappropriate because an antipsychotic is not indicated without psychosis or severe behavior requiring such therapy."
            },
            {
              "id": "B",
              "text": "Option A: Begin fluoxetine is inappropriate because an SSRI is not first-line treatment for isolated pica without a defined comorbid disorder."
            },
            {
              "id": "C",
              "text": "Option B: Begin methylphenidate is inappropriate because a stimulant is not indicated without evidence of ADHD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin risperidone is inappropriate because an antipsychotic is not indicated without psychosis or severe behavior requiring such therapy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe iron despite normal studies is inappropriate because empiric iron is inappropriate when iron studies are normal."
            },
            {
              "id": "B",
              "text": "Option A: Begin fluoxetine is inappropriate because an SSRI is not first-line treatment for isolated pica without a defined comorbid disorder."
            },
            {
              "id": "C",
              "text": "Option B: Begin methylphenidate is inappropriate because a stimulant is not indicated without evidence of ADHD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe iron despite normal studies is inappropriate because empiric iron is inappropriate when iron studies are normal."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend observation until adolescence is inappropriate because continued soil ingestion carries toxic and infectious risks and should not simply be observed."
            },
            {
              "id": "B",
              "text": "Option A: Begin fluoxetine is inappropriate because an SSRI is not first-line treatment for isolated pica without a defined comorbid disorder."
            },
            {
              "id": "C",
              "text": "Option B: Begin methylphenidate is inappropriate because a stimulant is not indicated without evidence of ADHD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend observation until adolescence is inappropriate because continued soil ingestion carries toxic and infectious risks and should not simply be observed."
        }
      }
    },
    {
      "externalId": "free137-i109-hypovolemic-hypernatremia-after-antibiotics",
      "expectedHashes": {
        "ranaze_step3_uat": "b18891aaa59efa1be42a9f655d355bde72239c204689ae1ca21e31542eeb2ff2",
        "ranaze_step3_prd": "b18891aaa59efa1be42a9f655d355bde72239c204689ae1ca21e31542eeb2ff2"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "5% dextrose in water is inappropriate because dextrose water provides free water but does not adequately restore the intravascular volume of a hypotensive patient with ongoing gastrointestinal losses."
            },
            {
              "id": "B",
              "text": "Option B: 0.45% sodium chloride is inappropriate because half-normal saline is hypotonic and is not the best first fluid for a patient with clear volume depletion and borderline shock physiology."
            },
            {
              "id": "C",
              "text": "Option C: 3% sodium chloride is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not for hypernatremia due to water loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "5% dextrose in water is inappropriate because dextrose water provides free water but does not adequately restore the intravascular volume of a hypotensive patient with ongoing gastrointestinal losses."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "0.45% sodium chloride is inappropriate because half-normal saline is hypotonic and is not the best first fluid for a patient with clear volume depletion and borderline shock physiology."
            },
            {
              "id": "B",
              "text": "Option A: 5% dextrose in water is inappropriate because dextrose water provides free water but does not adequately restore the intravascular volume of a hypotensive patient with ongoing gastrointestinal losses."
            },
            {
              "id": "C",
              "text": "Option C: 3% sodium chloride is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not for hypernatremia due to water loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "0.45% sodium chloride is inappropriate because half-normal saline is hypotonic and is not the best first fluid for a patient with clear volume depletion and borderline shock physiology."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "3% sodium chloride is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not for hypernatremia due to water loss."
            },
            {
              "id": "B",
              "text": "Option A: 5% dextrose in water is inappropriate because dextrose water provides free water but does not adequately restore the intravascular volume of a hypotensive patient with ongoing gastrointestinal losses."
            },
            {
              "id": "C",
              "text": "Option B: 0.45% sodium chloride is inappropriate because half-normal saline is hypotonic and is not the best first fluid for a patient with clear volume depletion and borderline shock physiology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "3% sodium chloride is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not for hypernatremia due to water loss."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous sodium bicarbonate is inappropriate because mild metabolic acidosis from diarrheal bicarbonate loss does not justify bicarbonate infusion, especially when urgent volume resuscitation is needed."
            },
            {
              "id": "B",
              "text": "Option A: 5% dextrose in water is inappropriate because dextrose water provides free water but does not adequately restore the intravascular volume of a hypotensive patient with ongoing gastrointestinal losses."
            },
            {
              "id": "C",
              "text": "Option B: 0.45% sodium chloride is inappropriate because half-normal saline is hypotonic and is not the best first fluid for a patient with clear volume depletion and borderline shock physiology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous sodium bicarbonate is inappropriate because mild metabolic acidosis from diarrheal bicarbonate loss does not justify bicarbonate infusion, especially when urgent volume resuscitation is needed."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "25% albumin is inappropriate because albumin is not first-line volume replacement for acute hypovolemia from infectious diarrhea without a specific indication such as cirrhosis-related complications."
            },
            {
              "id": "B",
              "text": "Option A: 5% dextrose in water is inappropriate because dextrose water provides free water but does not adequately restore the intravascular volume of a hypotensive patient with ongoing gastrointestinal losses."
            },
            {
              "id": "C",
              "text": "Option B: 0.45% sodium chloride is inappropriate because half-normal saline is hypotonic and is not the best first fluid for a patient with clear volume depletion and borderline shock physiology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "25% albumin is inappropriate because albumin is not first-line volume replacement for acute hypovolemia from infectious diarrhea without a specific indication such as cirrhosis-related complications."
        }
      }
    },
    {
      "externalId": "free137-i111-sickle-vertebral-osteomyelitis-empiric-antibiotics",
      "expectedHashes": {
        "ranaze_step3_uat": "9b049c0ff14e2cfefae3ad765c7223f3e695ff17fe597568b061814d373ce0ec",
        "ranaze_step3_prd": "9b049c0ff14e2cfefae3ad765c7223f3e695ff17fe597568b061814d373ce0ec"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ceftriaxone alone lacks reliable MRSA coverage."
            },
            {
              "id": "B",
              "text": "Option B: Nafcillin alone is inappropriate because nafcillin does not cover MRSA or Salmonella."
            },
            {
              "id": "C",
              "text": "Option C: Azithromycin plus cefazolin is inappropriate because azithromycin adds no appropriate coverage for vertebral osteomyelitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ceftriaxone alone lacks reliable MRSA coverage."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nafcillin alone is inappropriate because nafcillin does not cover MRSA or Salmonella."
            },
            {
              "id": "B",
              "text": "Option A: Ceftriaxone alone lacks reliable MRSA coverage."
            },
            {
              "id": "C",
              "text": "Option C: Azithromycin plus cefazolin is inappropriate because azithromycin adds no appropriate coverage for vertebral osteomyelitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nafcillin alone is inappropriate because nafcillin does not cover MRSA or Salmonella."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Azithromycin plus cefazolin is inappropriate because azithromycin adds no appropriate coverage for vertebral osteomyelitis."
            },
            {
              "id": "B",
              "text": "Option A: Ceftriaxone alone lacks reliable MRSA coverage."
            },
            {
              "id": "C",
              "text": "Option B: Nafcillin alone is inappropriate because nafcillin does not cover MRSA or Salmonella."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Azithromycin plus cefazolin is inappropriate because azithromycin adds no appropriate coverage for vertebral osteomyelitis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Metronidazole alone covers anaerobes but not the principal pathogens."
            },
            {
              "id": "B",
              "text": "Option A: Ceftriaxone alone lacks reliable MRSA coverage."
            },
            {
              "id": "C",
              "text": "Option B: Nafcillin alone is inappropriate because nafcillin does not cover MRSA or Salmonella."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Metronidazole alone covers anaerobes but not the principal pathogens."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fluconazole plus amphotericin B is inappropriate because fungal therapy is not indicated in this acute bacterial presentation."
            },
            {
              "id": "B",
              "text": "Option A: Ceftriaxone alone lacks reliable MRSA coverage."
            },
            {
              "id": "C",
              "text": "Option B: Nafcillin alone is inappropriate because nafcillin does not cover MRSA or Salmonella."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fluconazole plus amphotericin B is inappropriate because fungal therapy is not indicated in this acute bacterial presentation."
        }
      }
    },
    {
      "externalId": "free137-i112-appendicitis-analgesia-morphine",
      "expectedHashes": {
        "ranaze_step3_uat": "93f3b03d17364a2a379fb66fbac6d46b3f03b9b4a615d872101248134d890762",
        "ranaze_step3_prd": "93f3b03d17364a2a379fb66fbac6d46b3f03b9b4a615d872101248134d890762"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold analgesia to preserve examination findings is inappropriate because analgesia does not meaningfully prevent diagnosis and withholding it causes unnecessary suffering."
            },
            {
              "id": "B",
              "text": "Option C: Administer gabapentin is inappropriate because gabapentin is not appropriate for acute visceral abdominal pain."
            },
            {
              "id": "C",
              "text": "Option D: Administer lorazepam is inappropriate because lorazepam does not treat the pain and may impair assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold analgesia to preserve examination findings is inappropriate because analgesia does not meaningfully prevent diagnosis and withholding it causes unnecessary suffering."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer gabapentin is inappropriate because gabapentin is not appropriate for acute visceral abdominal pain."
            },
            {
              "id": "B",
              "text": "Option A: Withhold analgesia to preserve examination findings is inappropriate because analgesia does not meaningfully prevent diagnosis and withholding it causes unnecessary suffering."
            },
            {
              "id": "C",
              "text": "Option D: Administer lorazepam is inappropriate because lorazepam does not treat the pain and may impair assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer gabapentin is inappropriate because gabapentin is not appropriate for acute visceral abdominal pain."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer lorazepam is inappropriate because lorazepam does not treat the pain and may impair assessment."
            },
            {
              "id": "B",
              "text": "Option A: Withhold analgesia to preserve examination findings is inappropriate because analgesia does not meaningfully prevent diagnosis and withholding it causes unnecessary suffering."
            },
            {
              "id": "C",
              "text": "Option C: Administer gabapentin is inappropriate because gabapentin is not appropriate for acute visceral abdominal pain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer lorazepam is inappropriate because lorazepam does not treat the pain and may impair assessment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give only oral acetaminophen regardless of response is inappropriate because severe acute pain may require titrated intravenous opioid therapy rather than inadequate fixed oral therapy."
            },
            {
              "id": "B",
              "text": "Option A: Withhold analgesia to preserve examination findings is inappropriate because analgesia does not meaningfully prevent diagnosis and withholding it causes unnecessary suffering."
            },
            {
              "id": "C",
              "text": "Option C: Administer gabapentin is inappropriate because gabapentin is not appropriate for acute visceral abdominal pain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give only oral acetaminophen regardless of response is inappropriate because severe acute pain may require titrated intravenous opioid therapy rather than inadequate fixed oral therapy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with return precautions is inappropriate because fever and focal right lower quadrant tenderness require ongoing urgent evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Withhold analgesia to preserve examination findings is inappropriate because analgesia does not meaningfully prevent diagnosis and withholding it causes unnecessary suffering."
            },
            {
              "id": "C",
              "text": "Option C: Administer gabapentin is inappropriate because gabapentin is not appropriate for acute visceral abdominal pain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with return precautions is inappropriate because fever and focal right lower quadrant tenderness require ongoing urgent evaluation."
        }
      }
    },
    {
      "externalId": "free137-i113-ichthyosis-vulgaris-lactic-acid",
      "expectedHashes": {
        "ranaze_step3_uat": "b571a43c7d2a2d331eb9849eb07c45eee9b85a6dbd528e1e95b8acad9f73df6f",
        "ranaze_step3_prd": "b571a43c7d2a2d331eb9849eb07c45eee9b85a6dbd528e1e95b8acad9f73df6f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral isotretinoin is inappropriate because systemic retinoids are unnecessary for typical mild ichthyosis vulgaris and have substantial toxicity."
            },
            {
              "id": "B",
              "text": "Option B: Topical ketoconazole is inappropriate because the distribution and lifelong familial course do not suggest fungal infection."
            },
            {
              "id": "C",
              "text": "Option D: High-potency topical corticosteroid is inappropriate because corticosteroids treat inflammatory dermatoses, not the primary scaling defect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral isotretinoin is inappropriate because systemic retinoids are unnecessary for typical mild ichthyosis vulgaris and have substantial toxicity."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical ketoconazole is inappropriate because the distribution and lifelong familial course do not suggest fungal infection."
            },
            {
              "id": "B",
              "text": "Option A: Oral isotretinoin is inappropriate because systemic retinoids are unnecessary for typical mild ichthyosis vulgaris and have substantial toxicity."
            },
            {
              "id": "C",
              "text": "Option D: High-potency topical corticosteroid is inappropriate because corticosteroids treat inflammatory dermatoses, not the primary scaling defect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical ketoconazole is inappropriate because the distribution and lifelong familial course do not suggest fungal infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-potency topical corticosteroid is inappropriate because corticosteroids treat inflammatory dermatoses, not the primary scaling defect."
            },
            {
              "id": "B",
              "text": "Option A: Oral isotretinoin is inappropriate because systemic retinoids are unnecessary for typical mild ichthyosis vulgaris and have substantial toxicity."
            },
            {
              "id": "C",
              "text": "Option B: Topical ketoconazole is inappropriate because the distribution and lifelong familial course do not suggest fungal infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-potency topical corticosteroid is inappropriate because corticosteroids treat inflammatory dermatoses, not the primary scaling defect."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Antibacterial soap twice daily is inappropriate because harsh soaps worsen xerosis."
            },
            {
              "id": "B",
              "text": "Option A: Oral isotretinoin is inappropriate because systemic retinoids are unnecessary for typical mild ichthyosis vulgaris and have substantial toxicity."
            },
            {
              "id": "C",
              "text": "Option B: Topical ketoconazole is inappropriate because the distribution and lifelong familial course do not suggest fungal infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Antibacterial soap twice daily is inappropriate because harsh soaps worsen xerosis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral terbinafine is inappropriate because oral antifungal therapy is not indicated without dermatophyte infection."
            },
            {
              "id": "B",
              "text": "Option A: Oral isotretinoin is inappropriate because systemic retinoids are unnecessary for typical mild ichthyosis vulgaris and have substantial toxicity."
            },
            {
              "id": "C",
              "text": "Option B: Topical ketoconazole is inappropriate because the distribution and lifelong familial course do not suggest fungal infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral terbinafine is inappropriate because oral antifungal therapy is not indicated without dermatophyte infection."
        }
      }
    },
    {
      "externalId": "free137-i114-urinary-retention-failed-catheter-suprapubic",
      "expectedHashes": {
        "ranaze_step3_uat": "e387f91aaec7343e7b877c4dbc75860339430305463725d7149e286215b2081f",
        "ranaze_step3_prd": "e387f91aaec7343e7b877c4dbc75860339430305463725d7149e286215b2081f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bethanechol therapy is inappropriate because bethanechol is not appropriate for mechanical obstruction and delays drainage."
            },
            {
              "id": "B",
              "text": "Option B: Tamsulosin therapy is inappropriate because an alpha blocker will not immediately relieve retention when catheter passage is impossible and the prostate is normal."
            },
            {
              "id": "C",
              "text": "Option C: Immediate hemodialysis without drainage is inappropriate because dialysis does not correct the obstructed urinary tract and is not first-line without refractory indications."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bethanechol therapy is inappropriate because bethanechol is not appropriate for mechanical obstruction and delays drainage."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tamsulosin therapy is inappropriate because an alpha blocker will not immediately relieve retention when catheter passage is impossible and the prostate is normal."
            },
            {
              "id": "B",
              "text": "Option A: Bethanechol therapy is inappropriate because bethanechol is not appropriate for mechanical obstruction and delays drainage."
            },
            {
              "id": "C",
              "text": "Option C: Immediate hemodialysis without drainage is inappropriate because dialysis does not correct the obstructed urinary tract and is not first-line without refractory indications."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tamsulosin therapy is inappropriate because an alpha blocker will not immediately relieve retention when catheter passage is impossible and the prostate is normal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate hemodialysis without drainage is inappropriate because dialysis does not correct the obstructed urinary tract and is not first-line without refractory indications."
            },
            {
              "id": "B",
              "text": "Option A: Bethanechol therapy is inappropriate because bethanechol is not appropriate for mechanical obstruction and delays drainage."
            },
            {
              "id": "C",
              "text": "Option B: Tamsulosin therapy is inappropriate because an alpha blocker will not immediately relieve retention when catheter passage is impossible and the prostate is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate hemodialysis without drainage is inappropriate because dialysis does not correct the obstructed urinary tract and is not first-line without refractory indications."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ultrafiltration removes volume but does not decompress the bladder."
            },
            {
              "id": "B",
              "text": "Option A: Bethanechol therapy is inappropriate because bethanechol is not appropriate for mechanical obstruction and delays drainage."
            },
            {
              "id": "C",
              "text": "Option B: Tamsulosin therapy is inappropriate because an alpha blocker will not immediately relieve retention when catheter passage is impossible and the prostate is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ultrafiltration removes volume but does not decompress the bladder."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat forceful urethral catheterization is inappropriate because repeated forceful attempts risk urethral injury and false passage."
            },
            {
              "id": "B",
              "text": "Option A: Bethanechol therapy is inappropriate because bethanechol is not appropriate for mechanical obstruction and delays drainage."
            },
            {
              "id": "C",
              "text": "Option B: Tamsulosin therapy is inappropriate because an alpha blocker will not immediately relieve retention when catheter passage is impossible and the prostate is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat forceful urethral catheterization is inappropriate because repeated forceful attempts risk urethral injury and false passage."
        }
      }
    },
    {
      "externalId": "free137-i116-pediatric-dka-cerebral-edema-hypertonic-therapy",
      "expectedHashes": {
        "ranaze_step3_uat": "ed6f39b8b3718a4e4e74c81f138709e45aa1afc09d52a97e10863e456517b0d7",
        "ranaze_step3_prd": "ed6f39b8b3718a4e4e74c81f138709e45aa1afc09d52a97e10863e456517b0d7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sodium bicarbonate is inappropriate because bicarbonate is generally avoided in DKA and does not treat cerebral edema."
            },
            {
              "id": "B",
              "text": "Option B: Dexamethasone is inappropriate because corticosteroids are not effective treatment for DKA-related cerebral injury."
            },
            {
              "id": "C",
              "text": "Option C: Concentrated dextrose is inappropriate because dextrose may be added later to continue insulin safely but does not treat this neurologic emergency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sodium bicarbonate is inappropriate because bicarbonate is generally avoided in DKA and does not treat cerebral edema."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dexamethasone is inappropriate because corticosteroids are not effective treatment for DKA-related cerebral injury."
            },
            {
              "id": "B",
              "text": "Option A: Sodium bicarbonate is inappropriate because bicarbonate is generally avoided in DKA and does not treat cerebral edema."
            },
            {
              "id": "C",
              "text": "Option C: Concentrated dextrose is inappropriate because dextrose may be added later to continue insulin safely but does not treat this neurologic emergency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dexamethasone is inappropriate because corticosteroids are not effective treatment for DKA-related cerebral injury."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Concentrated dextrose is inappropriate because dextrose may be added later to continue insulin safely but does not treat this neurologic emergency."
            },
            {
              "id": "B",
              "text": "Option A: Sodium bicarbonate is inappropriate because bicarbonate is generally avoided in DKA and does not treat cerebral edema."
            },
            {
              "id": "C",
              "text": "Option B: Dexamethasone is inappropriate because corticosteroids are not effective treatment for DKA-related cerebral injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Concentrated dextrose is inappropriate because dextrose may be added later to continue insulin safely but does not treat this neurologic emergency."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Furosemide is not recommended treatment for DKA cerebral edema."
            },
            {
              "id": "B",
              "text": "Option A: Sodium bicarbonate is inappropriate because bicarbonate is generally avoided in DKA and does not treat cerebral edema."
            },
            {
              "id": "C",
              "text": "Option B: Dexamethasone is inappropriate because corticosteroids are not effective treatment for DKA-related cerebral injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Furosemide is not recommended treatment for DKA cerebral edema."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Additional insulin bolus is inappropriate because an insulin bolus may accelerate osmotic shifts and does not treat cerebral injury."
            },
            {
              "id": "B",
              "text": "Option A: Sodium bicarbonate is inappropriate because bicarbonate is generally avoided in DKA and does not treat cerebral edema."
            },
            {
              "id": "C",
              "text": "Option B: Dexamethasone is inappropriate because corticosteroids are not effective treatment for DKA-related cerebral injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Additional insulin bolus is inappropriate because an insulin bolus may accelerate osmotic shifts and does not treat cerebral injury."
        }
      }
    },
    {
      "externalId": "free137-i117-vasomotor-symptoms-estrogen-after-hysterectomy",
      "expectedHashes": {
        "ranaze_step3_uat": "dbf7531d596e90ea3b1923feb11cd61536d76521b6108aa4e64992a191eaf3f9",
        "ranaze_step3_prd": "dbf7531d596e90ea3b1923feb11cd61536d76521b6108aa4e64992a191eaf3f9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Combined estrogen-progestogen therapy is inappropriate because adding a progestogen is unnecessary after total hysterectomy and adds adverse effects."
            },
            {
              "id": "B",
              "text": "Option C: Raloxifene can worsen hot flashes and is not used to treat vasomotor symptoms."
            },
            {
              "id": "C",
              "text": "Option D: Isoniazid does not treat menopausal vasomotor symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Combined estrogen-progestogen therapy is inappropriate because adding a progestogen is unnecessary after total hysterectomy and adds adverse effects."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Raloxifene can worsen hot flashes and is not used to treat vasomotor symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Combined estrogen-progestogen therapy is inappropriate because adding a progestogen is unnecessary after total hysterectomy and adds adverse effects."
            },
            {
              "id": "C",
              "text": "Option D: Isoniazid does not treat menopausal vasomotor symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Raloxifene can worsen hot flashes and is not used to treat vasomotor symptoms."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isoniazid does not treat menopausal vasomotor symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Combined estrogen-progestogen therapy is inappropriate because adding a progestogen is unnecessary after total hysterectomy and adds adverse effects."
            },
            {
              "id": "C",
              "text": "Option C: Raloxifene can worsen hot flashes and is not used to treat vasomotor symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isoniazid does not treat menopausal vasomotor symptoms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Testosterone is not indicated for hot flashes."
            },
            {
              "id": "B",
              "text": "Option B: Combined estrogen-progestogen therapy is inappropriate because adding a progestogen is unnecessary after total hysterectomy and adds adverse effects."
            },
            {
              "id": "C",
              "text": "Option C: Raloxifene can worsen hot flashes and is not used to treat vasomotor symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Testosterone is not indicated for hot flashes."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long-term high-dose clonidine as first-line therapy is inappropriate because clonidine is less effective and generally not preferred when hormone therapy is appropriate."
            },
            {
              "id": "B",
              "text": "Option B: Combined estrogen-progestogen therapy is inappropriate because adding a progestogen is unnecessary after total hysterectomy and adds adverse effects."
            },
            {
              "id": "C",
              "text": "Option C: Raloxifene can worsen hot flashes and is not used to treat vasomotor symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long-term high-dose clonidine as first-line therapy is inappropriate because clonidine is less effective and generally not preferred when hormone therapy is appropriate."
        }
      }
    },
    {
      "externalId": "free137-i121-diarrheal-volume-depletion-isotonic-saline",
      "expectedHashes": {
        "ranaze_step3_uat": "4541cc671de8c4db9b1057c891644c98ed7b738795befaa2689dc084643d27b9",
        "ranaze_step3_prd": "4541cc671de8c4db9b1057c891644c98ed7b738795befaa2689dc084643d27b9"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "3% hypertonic saline is inappropriate because hypertonic saline would worsen hypernatremia and is not indicated."
            },
            {
              "id": "B",
              "text": "Option B: Sodium bicarbonate infusion is inappropriate because there is no severe acidemia requiring bicarbonate."
            },
            {
              "id": "C",
              "text": "Option C: 5% dextrose in water is inappropriate because d5W distributes as free water and is not the initial fluid for hemodynamic volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "3% hypertonic saline is inappropriate because hypertonic saline would worsen hypernatremia and is not indicated."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sodium bicarbonate infusion is inappropriate because there is no severe acidemia requiring bicarbonate."
            },
            {
              "id": "B",
              "text": "Option A: 3% hypertonic saline is inappropriate because hypertonic saline would worsen hypernatremia and is not indicated."
            },
            {
              "id": "C",
              "text": "Option C: 5% dextrose in water is inappropriate because d5W distributes as free water and is not the initial fluid for hemodynamic volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sodium bicarbonate infusion is inappropriate because there is no severe acidemia requiring bicarbonate."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "5% dextrose in water is inappropriate because d5W distributes as free water and is not the initial fluid for hemodynamic volume depletion."
            },
            {
              "id": "B",
              "text": "Option A: 3% hypertonic saline is inappropriate because hypertonic saline would worsen hypernatremia and is not indicated."
            },
            {
              "id": "C",
              "text": "Option B: Sodium bicarbonate infusion is inappropriate because there is no severe acidemia requiring bicarbonate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "5% dextrose in water is inappropriate because d5W distributes as free water and is not the initial fluid for hemodynamic volume depletion."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Free water by rapid intravenous bolus is inappropriate because pure free water cannot be given intravenously and would be unsafe."
            },
            {
              "id": "B",
              "text": "Option A: 3% hypertonic saline is inappropriate because hypertonic saline would worsen hypernatremia and is not indicated."
            },
            {
              "id": "C",
              "text": "Option B: Sodium bicarbonate infusion is inappropriate because there is no severe acidemia requiring bicarbonate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Free water by rapid intravenous bolus is inappropriate because pure free water cannot be given intravenously and would be unsafe."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Albumin only is inappropriate because albumin is not necessary for routine diarrheal volume loss."
            },
            {
              "id": "B",
              "text": "Option A: 3% hypertonic saline is inappropriate because hypertonic saline would worsen hypernatremia and is not indicated."
            },
            {
              "id": "C",
              "text": "Option B: Sodium bicarbonate infusion is inappropriate because there is no severe acidemia requiring bicarbonate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Albumin only is inappropriate because albumin is not necessary for routine diarrheal volume loss."
        }
      }
    },
    {
      "externalId": "free137-i125-bupropion-nicotine-hypertension-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "13e0adf5c886b3f166dfaf53136b7cd8f26c0bcdd5adeb7988fba31b6bf85ca1",
        "ranaze_step3_prd": "13e0adf5c886b3f166dfaf53136b7cd8f26c0bcdd5adeb7988fba31b6bf85ca1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This combination does not characteristically cause hypothermia."
            },
            {
              "id": "B",
              "text": "Option C: Polyuria is not an expected interaction."
            },
            {
              "id": "C",
              "text": "Option D: Neither therapy commonly causes acute kidney failure in this setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This combination does not characteristically cause hypothermia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Polyuria is not an expected interaction."
            },
            {
              "id": "B",
              "text": "Option A: This combination does not characteristically cause hypothermia."
            },
            {
              "id": "C",
              "text": "Option D: Neither therapy commonly causes acute kidney failure in this setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Polyuria is not an expected interaction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neither therapy commonly causes acute kidney failure in this setting."
            },
            {
              "id": "B",
              "text": "Option A: This combination does not characteristically cause hypothermia."
            },
            {
              "id": "C",
              "text": "Option C: Polyuria is not an expected interaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neither therapy commonly causes acute kidney failure in this setting."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The combination does not cause severe hypoglycemia in a patient without diabetes."
            },
            {
              "id": "B",
              "text": "Option A: This combination does not characteristically cause hypothermia."
            },
            {
              "id": "C",
              "text": "Option C: Polyuria is not an expected interaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The combination does not cause severe hypoglycemia in a patient without diabetes."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neutropenia is not the principal combined risk."
            },
            {
              "id": "B",
              "text": "Option A: This combination does not characteristically cause hypothermia."
            },
            {
              "id": "C",
              "text": "Option C: Polyuria is not an expected interaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neutropenia is not the principal combined risk."
        }
      }
    },
    {
      "externalId": "free137-i126-bell-palsy-favorable-prognosis",
      "expectedHashes": {
        "ranaze_step3_uat": "aec67ebc2e7f7a8567328baf5050912277b2845c0c1711e2a31d2cf3b6fc1591",
        "ranaze_step3_prd": "aec67ebc2e7f7a8567328baf5050912277b2845c0c1711e2a31d2cf3b6fc1591"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recovery cannot be estimated without angiography is inappropriate because the classic peripheral facial palsy pattern does not require angiography for prognostication."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture is required before prognosis can be discussed is inappropriate because lumbar puncture is not routinely needed without features of infection or another neurologic disorder."
            },
            {
              "id": "C",
              "text": "Option D: Functional recovery is unlikely even with treatment is inappropriate because most patients recover functional facial movement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recovery cannot be estimated without angiography is inappropriate because the classic peripheral facial palsy pattern does not require angiography for prognostication."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar puncture is required before prognosis can be discussed is inappropriate because lumbar puncture is not routinely needed without features of infection or another neurologic disorder."
            },
            {
              "id": "B",
              "text": "Option A: Recovery cannot be estimated without angiography is inappropriate because the classic peripheral facial palsy pattern does not require angiography for prognostication."
            },
            {
              "id": "C",
              "text": "Option D: Functional recovery is unlikely even with treatment is inappropriate because most patients recover functional facial movement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar puncture is required before prognosis can be discussed is inappropriate because lumbar puncture is not routinely needed without features of infection or another neurologic disorder."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Functional recovery is unlikely even with treatment is inappropriate because most patients recover functional facial movement."
            },
            {
              "id": "B",
              "text": "Option A: Recovery cannot be estimated without angiography is inappropriate because the classic peripheral facial palsy pattern does not require angiography for prognostication."
            },
            {
              "id": "C",
              "text": "Option B: Lumbar puncture is required before prognosis can be discussed is inappropriate because lumbar puncture is not routinely needed without features of infection or another neurologic disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Functional recovery is unlikely even with treatment is inappropriate because most patients recover functional facial movement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Progressive bilateral paralysis is expected is inappropriate because progression to bilateral paralysis is not the expected course."
            },
            {
              "id": "B",
              "text": "Option A: Recovery cannot be estimated without angiography is inappropriate because the classic peripheral facial palsy pattern does not require angiography for prognostication."
            },
            {
              "id": "C",
              "text": "Option B: Lumbar puncture is required before prognosis can be discussed is inappropriate because lumbar puncture is not routinely needed without features of infection or another neurologic disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Progressive bilateral paralysis is expected is inappropriate because progression to bilateral paralysis is not the expected course."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Permanent aphasia is a common outcome is inappropriate because bell palsy affects the facial nerve and does not cause aphasia."
            },
            {
              "id": "B",
              "text": "Option A: Recovery cannot be estimated without angiography is inappropriate because the classic peripheral facial palsy pattern does not require angiography for prognostication."
            },
            {
              "id": "C",
              "text": "Option B: Lumbar puncture is required before prognosis can be discussed is inappropriate because lumbar puncture is not routinely needed without features of infection or another neurologic disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Permanent aphasia is a common outcome is inappropriate because bell palsy affects the facial nerve and does not cause aphasia."
        }
      }
    },
    {
      "externalId": "free137-i130-cold-urticaria-avoidance",
      "expectedHashes": {
        "ranaze_step3_uat": "98414359a19fe9aec88f81b089e6dfc5033b3910b04ac46cd6e02ece2027e069",
        "ranaze_step3_prd": "98414359a19fe9aec88f81b089e6dfc5033b3910b04ac46cd6e02ece2027e069"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use topical hydrocortisone before swimming is inappropriate because topical corticosteroids do not prevent histamine-mediated cold urticaria."
            },
            {
              "id": "B",
              "text": "Option C: Take pseudoephedrine daily is inappropriate because pseudoephedrine is not treatment for cold urticaria."
            },
            {
              "id": "C",
              "text": "Option D: Carry out supervised cold exposure to induce tolerance is inappropriate because unsupervised or deliberate reexposure may provoke anaphylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use topical hydrocortisone before swimming is inappropriate because topical corticosteroids do not prevent histamine-mediated cold urticaria."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Take pseudoephedrine daily is inappropriate because pseudoephedrine is not treatment for cold urticaria."
            },
            {
              "id": "B",
              "text": "Option B: Use topical hydrocortisone before swimming is inappropriate because topical corticosteroids do not prevent histamine-mediated cold urticaria."
            },
            {
              "id": "C",
              "text": "Option D: Carry out supervised cold exposure to induce tolerance is inappropriate because unsupervised or deliberate reexposure may provoke anaphylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Take pseudoephedrine daily is inappropriate because pseudoephedrine is not treatment for cold urticaria."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carry out supervised cold exposure to induce tolerance is inappropriate because unsupervised or deliberate reexposure may provoke anaphylaxis."
            },
            {
              "id": "B",
              "text": "Option B: Use topical hydrocortisone before swimming is inappropriate because topical corticosteroids do not prevent histamine-mediated cold urticaria."
            },
            {
              "id": "C",
              "text": "Option C: Take pseudoephedrine daily is inappropriate because pseudoephedrine is not treatment for cold urticaria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carry out supervised cold exposure to induce tolerance is inappropriate because unsupervised or deliberate reexposure may provoke anaphylaxis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin systemic corticosteroids indefinitely is inappropriate because chronic systemic corticosteroids have unfavorable risk and are not first-line."
            },
            {
              "id": "B",
              "text": "Option B: Use topical hydrocortisone before swimming is inappropriate because topical corticosteroids do not prevent histamine-mediated cold urticaria."
            },
            {
              "id": "C",
              "text": "Option C: Take pseudoephedrine daily is inappropriate because pseudoephedrine is not treatment for cold urticaria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin systemic corticosteroids indefinitely is inappropriate because chronic systemic corticosteroids have unfavorable risk and are not first-line."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hospitalize for observation despite complete resolution is inappropriate because resolved localized wheals without systemic symptoms do not require admission."
            },
            {
              "id": "B",
              "text": "Option B: Use topical hydrocortisone before swimming is inappropriate because topical corticosteroids do not prevent histamine-mediated cold urticaria."
            },
            {
              "id": "C",
              "text": "Option C: Take pseudoephedrine daily is inappropriate because pseudoephedrine is not treatment for cold urticaria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hospitalize for observation despite complete resolution is inappropriate because resolved localized wheals without systemic symptoms do not require admission."
        }
      }
    },
    {
      "externalId": "free137-i131-pregnancy-inpatient-cap-beta-lactam-macrolide",
      "expectedHashes": {
        "ranaze_step3_uat": "4368442f4a62ce7e793107851e5242ea05da37089ba95e1b16501b7c93ef1bc6",
        "ranaze_step3_prd": "4368442f4a62ce7e793107851e5242ea05da37089ba95e1b16501b7c93ef1bc6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ceftriaxone alone is inappropriate because a beta-lactam alone lacks reliable atypical coverage despite features suggesting Legionella."
            },
            {
              "id": "B",
              "text": "Option C: Levofloxacin alone is inappropriate because fluoroquinolones are generally avoided in pregnancy when safer effective alternatives exist."
            },
            {
              "id": "C",
              "text": "Option D: Piperacillin-tazobactam alone is inappropriate because piperacillin-tazobactam does not reliably cover atypical pathogens and is unnecessarily broad without resistant-pathogen risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ceftriaxone alone is inappropriate because a beta-lactam alone lacks reliable atypical coverage despite features suggesting Legionella."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Levofloxacin alone is inappropriate because fluoroquinolones are generally avoided in pregnancy when safer effective alternatives exist."
            },
            {
              "id": "B",
              "text": "Option B: Ceftriaxone alone is inappropriate because a beta-lactam alone lacks reliable atypical coverage despite features suggesting Legionella."
            },
            {
              "id": "C",
              "text": "Option D: Piperacillin-tazobactam alone is inappropriate because piperacillin-tazobactam does not reliably cover atypical pathogens and is unnecessarily broad without resistant-pathogen risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Levofloxacin alone is inappropriate because fluoroquinolones are generally avoided in pregnancy when safer effective alternatives exist."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Piperacillin-tazobactam alone is inappropriate because piperacillin-tazobactam does not reliably cover atypical pathogens and is unnecessarily broad without resistant-pathogen risk."
            },
            {
              "id": "B",
              "text": "Option B: Ceftriaxone alone is inappropriate because a beta-lactam alone lacks reliable atypical coverage despite features suggesting Legionella."
            },
            {
              "id": "C",
              "text": "Option C: Levofloxacin alone is inappropriate because fluoroquinolones are generally avoided in pregnancy when safer effective alternatives exist."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Piperacillin-tazobactam alone is inappropriate because piperacillin-tazobactam does not reliably cover atypical pathogens and is unnecessarily broad without resistant-pathogen risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Doxycycline plus gentamicin is inappropriate because doxycycline is generally avoided during pregnancy, and gentamicin is not standard CAP therapy."
            },
            {
              "id": "B",
              "text": "Option B: Ceftriaxone alone is inappropriate because a beta-lactam alone lacks reliable atypical coverage despite features suggesting Legionella."
            },
            {
              "id": "C",
              "text": "Option C: Levofloxacin alone is inappropriate because fluoroquinolones are generally avoided in pregnancy when safer effective alternatives exist."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Doxycycline plus gentamicin is inappropriate because doxycycline is generally avoided during pregnancy, and gentamicin is not standard CAP therapy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Trimethoprim-sulfamethoxazole alone is inappropriate because trimethoprim-sulfamethoxazole is not an appropriate empiric regimen for severe CAP and has pregnancy-specific concerns."
            },
            {
              "id": "B",
              "text": "Option B: Ceftriaxone alone is inappropriate because a beta-lactam alone lacks reliable atypical coverage despite features suggesting Legionella."
            },
            {
              "id": "C",
              "text": "Option C: Levofloxacin alone is inappropriate because fluoroquinolones are generally avoided in pregnancy when safer effective alternatives exist."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Trimethoprim-sulfamethoxazole alone is inappropriate because trimethoprim-sulfamethoxazole is not an appropriate empiric regimen for severe CAP and has pregnancy-specific concerns."
        }
      }
    },
    {
      "externalId": "free137-i133-adrenal-crisis-hydrocortisone",
      "expectedHashes": {
        "ranaze_step3_uat": "b6f0f31e2babac7dc5e6fed31fe5ef30a1d4c9a1ebc961409b7510dd4adc0316",
        "ranaze_step3_prd": "b6f0f31e2babac7dc5e6fed31fe5ef30a1d4c9a1ebc961409b7510dd4adc0316"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Calcitonin treats hypercalcemia, which is not present."
            },
            {
              "id": "B",
              "text": "Option B: Fludrocortisone alone lacks sufficient glucocorticoid activity for adrenal crisis."
            },
            {
              "id": "C",
              "text": "Option D: Levothyroxine is inappropriate because thyroid hormone can precipitate worsening adrenal crisis if glucocorticoid deficiency is untreated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Calcitonin treats hypercalcemia, which is not present."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fludrocortisone alone lacks sufficient glucocorticoid activity for adrenal crisis."
            },
            {
              "id": "B",
              "text": "Option A: Calcitonin treats hypercalcemia, which is not present."
            },
            {
              "id": "C",
              "text": "Option D: Levothyroxine is inappropriate because thyroid hormone can precipitate worsening adrenal crisis if glucocorticoid deficiency is untreated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fludrocortisone alone lacks sufficient glucocorticoid activity for adrenal crisis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Levothyroxine is inappropriate because thyroid hormone can precipitate worsening adrenal crisis if glucocorticoid deficiency is untreated."
            },
            {
              "id": "B",
              "text": "Option A: Calcitonin treats hypercalcemia, which is not present."
            },
            {
              "id": "C",
              "text": "Option B: Fludrocortisone alone lacks sufficient glucocorticoid activity for adrenal crisis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Levothyroxine is inappropriate because thyroid hormone can precipitate worsening adrenal crisis if glucocorticoid deficiency is untreated."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mitotane suppresses adrenal steroid production and would worsen the condition."
            },
            {
              "id": "B",
              "text": "Option A: Calcitonin treats hypercalcemia, which is not present."
            },
            {
              "id": "C",
              "text": "Option B: Fludrocortisone alone lacks sufficient glucocorticoid activity for adrenal crisis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mitotane suppresses adrenal steroid production and would worsen the condition."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Insulin without dextrose would worsen hypoglycemia and does not replace cortisol."
            },
            {
              "id": "B",
              "text": "Option A: Calcitonin treats hypercalcemia, which is not present."
            },
            {
              "id": "C",
              "text": "Option B: Fludrocortisone alone lacks sufficient glucocorticoid activity for adrenal crisis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Insulin without dextrose would worsen hypoglycemia and does not replace cortisol."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-acute-liver-failure-nac-transfer",
      "expectedHashes": {
        "ranaze_step3_uat": "62497661128365c2e0b283db99c7f3111dd4dc3bdb816fdffb697de1a99307ee",
        "ranaze_step3_prd": "62497661128365c2e0b283db99c7f3111dd4dc3bdb816fdffb697de1a99307ee"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for the acetaminophen concentration before treatment is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            },
            {
              "id": "B",
              "text": "Option C: Begin lactulose only and arrange routine clinic follow-up is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            },
            {
              "id": "C",
              "text": "Option D: Administer methotrexate is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for the acetaminophen concentration before treatment is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin lactulose only and arrange routine clinic follow-up is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            },
            {
              "id": "B",
              "text": "Option B: Wait for the acetaminophen concentration before treatment is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            },
            {
              "id": "C",
              "text": "Option D: Administer methotrexate is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin lactulose only and arrange routine clinic follow-up is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer methotrexate is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            },
            {
              "id": "B",
              "text": "Option B: Wait for the acetaminophen concentration before treatment is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            },
            {
              "id": "C",
              "text": "Option C: Begin lactulose only and arrange routine clinic follow-up is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer methotrexate is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform elective liver biopsy first is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            },
            {
              "id": "B",
              "text": "Option B: Wait for the acetaminophen concentration before treatment is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            },
            {
              "id": "C",
              "text": "Option C: Begin lactulose only and arrange routine clinic follow-up is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform elective liver biopsy first is inappropriate because this choice does not address the decisive finding: new encephalopathy and severe coagulopathy with massive aminotransferase elevation. a late acetaminophen level can be low despite severe toxicity."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-amniotic-fluid-embolism-resuscitation",
      "expectedHashes": {
        "ranaze_step3_uat": "e0ee459b0a36ff444766b65b6fbc3acb15a1b30e96bd731d8d52be5a1fe7ee1a",
        "ranaze_step3_prd": "e0ee459b0a36ff444766b65b6fbc3acb15a1b30e96bd731d8d52be5a1fe7ee1a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Heparin infusion for presumed pulmonary thromboembolism is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            },
            {
              "id": "B",
              "text": "Option C: Immediate bronchoscopy to remove an obstruction is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            },
            {
              "id": "C",
              "text": "Option D: High-dose epinephrine autoinjector only is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Heparin infusion for presumed pulmonary thromboembolism is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate bronchoscopy to remove an obstruction is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            },
            {
              "id": "B",
              "text": "Option B: Heparin infusion for presumed pulmonary thromboembolism is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            },
            {
              "id": "C",
              "text": "Option D: High-dose epinephrine autoinjector only is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate bronchoscopy to remove an obstruction is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose epinephrine autoinjector only is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            },
            {
              "id": "B",
              "text": "Option B: Heparin infusion for presumed pulmonary thromboembolism is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            },
            {
              "id": "C",
              "text": "Option C: Immediate bronchoscopy to remove an obstruction is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose epinephrine autoinjector only is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for a confirmatory serum test before treatment is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            },
            {
              "id": "B",
              "text": "Option B: Heparin infusion for presumed pulmonary thromboembolism is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            },
            {
              "id": "C",
              "text": "Option C: Immediate bronchoscopy to remove an obstruction is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for a confirmatory serum test before treatment is inappropriate because this choice does not address the decisive finding: peripartum collapse followed by DIC. anticoagulation can worsen the profound coagulopathy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-anti-gbm-pulmonary-renal-treatment",
      "expectedHashes": {
        "ranaze_step3_uat": "d0af9cce75875c24eba2e25338528d9e29bcd8cde2e16df569b55eb12eb7d243",
        "ranaze_step3_prd": "d0af9cce75875c24eba2e25338528d9e29bcd8cde2e16df569b55eb12eb7d243"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Glucocorticoids alone is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            },
            {
              "id": "B",
              "text": "Option C: Rituximab alone after renal biopsy is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            },
            {
              "id": "C",
              "text": "Option D: Hemodialysis without immunosuppression is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Glucocorticoids alone is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Rituximab alone after renal biopsy is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            },
            {
              "id": "B",
              "text": "Option B: Glucocorticoids alone is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            },
            {
              "id": "C",
              "text": "Option D: Hemodialysis without immunosuppression is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Rituximab alone after renal biopsy is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hemodialysis without immunosuppression is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            },
            {
              "id": "B",
              "text": "Option B: Glucocorticoids alone is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            },
            {
              "id": "C",
              "text": "Option C: Rituximab alone after renal biopsy is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hemodialysis without immunosuppression is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Broad-spectrum antibiotics only is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            },
            {
              "id": "B",
              "text": "Option B: Glucocorticoids alone is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            },
            {
              "id": "C",
              "text": "Option C: Rituximab alone after renal biopsy is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Broad-spectrum antibiotics only is inappropriate because this choice does not address the decisive finding: pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody. dialysis supports kidney failure but does not stop antibody injury."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-ascending-cholangitis-urgent-ercp",
      "expectedHashes": {
        "ranaze_step3_uat": "3ec965d2343edc810ee7f28693cbe6da4607385679a40bcf350ffc534c40dda2",
        "ranaze_step3_prd": "3ec965d2343edc810ee7f28693cbe6da4607385679a40bcf350ffc534c40dda2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elective cholecystectomy in 6 weeks without drainage is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            },
            {
              "id": "B",
              "text": "Option C: HIDA scan before treatment is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            },
            {
              "id": "C",
              "text": "Option D: Percutaneous liver biopsy is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elective cholecystectomy in 6 weeks without drainage is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "HIDA scan before treatment is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            },
            {
              "id": "B",
              "text": "Option B: Elective cholecystectomy in 6 weeks without drainage is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            },
            {
              "id": "C",
              "text": "Option D: Percutaneous liver biopsy is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "HIDA scan before treatment is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Percutaneous liver biopsy is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            },
            {
              "id": "B",
              "text": "Option B: Elective cholecystectomy in 6 weeks without drainage is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            },
            {
              "id": "C",
              "text": "Option C: HIDA scan before treatment is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Percutaneous liver biopsy is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral ursodiol is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            },
            {
              "id": "B",
              "text": "Option B: Elective cholecystectomy in 6 weeks without drainage is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            },
            {
              "id": "C",
              "text": "Option C: HIDA scan before treatment is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral ursodiol is inappropriate because this choice does not address the decisive finding: shock, jaundice, and a ductal stone with biliary dilation. delayed elective surgery does not decompress the infected duct."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-atherosclerotic-ras-flash-pulmonary-edema",
      "expectedHashes": {
        "ranaze_step3_uat": "8d6b8c6811f65596fd420ddc0880b539eddd48b8973f274f93b84d5fc5a36713",
        "ranaze_step3_prd": "8d6b8c6811f65596fd420ddc0880b539eddd48b8973f274f93b84d5fc5a36713"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase the ACE inhibitor dose is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            },
            {
              "id": "B",
              "text": "Option C: Start high-dose glucocorticoids is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            },
            {
              "id": "C",
              "text": "Option D: Perform unilateral nephrectomy is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase the ACE inhibitor dose is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start high-dose glucocorticoids is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Increase the ACE inhibitor dose is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            },
            {
              "id": "C",
              "text": "Option D: Perform unilateral nephrectomy is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start high-dose glucocorticoids is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform unilateral nephrectomy is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Increase the ACE inhibitor dose is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            },
            {
              "id": "C",
              "text": "Option C: Start high-dose glucocorticoids is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform unilateral nephrectomy is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue medical therapy without further evaluation is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Increase the ACE inhibitor dose is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            },
            {
              "id": "C",
              "text": "Option C: Start high-dose glucocorticoids is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue medical therapy without further evaluation is inappropriate because this choice does not address the decisive finding: recurrent flash edema with bilateral severe stenosis. routine stenting is not indicated for stable incidental stenosis."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-cluster-randomized-analysis-unit",
      "expectedHashes": {
        "ranaze_step3_uat": "c68e7fe536a119582f1c7caac569c48d96a0f054586ea62cf13dff9880ac3b8a",
        "ranaze_step3_prd": "c68e7fe536a119582f1c7caac569c48d96a0f054586ea62cf13dff9880ac3b8a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The intervention effect will necessarily reverse direction is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            },
            {
              "id": "B",
              "text": "Option C: Selection bias will be eliminated is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            },
            {
              "id": "C",
              "text": "Option D: Statistical power will always decrease is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The intervention effect will necessarily reverse direction is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Selection bias will be eliminated is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            },
            {
              "id": "B",
              "text": "Option B: The intervention effect will necessarily reverse direction is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            },
            {
              "id": "C",
              "text": "Option D: Statistical power will always decrease is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Selection bias will be eliminated is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Statistical power will always decrease is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            },
            {
              "id": "B",
              "text": "Option B: The intervention effect will necessarily reverse direction is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            },
            {
              "id": "C",
              "text": "Option C: Selection bias will be eliminated is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Statistical power will always decrease is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The intracluster correlation will become zero is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            },
            {
              "id": "B",
              "text": "Option B: The intervention effect will necessarily reverse direction is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            },
            {
              "id": "C",
              "text": "Option C: Selection bias will be eliminated is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The intracluster correlation will become zero is inappropriate because this choice does not address the decisive finding: randomization occurred at the clinic level. ignoring clusters creates falsely narrow confidence intervals."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-competing-risk-cumulative-incidence",
      "expectedHashes": {
        "ranaze_step3_uat": "ec0675b567cb6c0947f54d7f09f366b5e97bf5b4c3440fc93d6d5b766b6cd6c3",
        "ranaze_step3_prd": "ec0675b567cb6c0947f54d7f09f366b5e97bf5b4c3440fc93d6d5b766b6cd6c3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Kaplan-Meier analysis censoring deaths as ordinary noninformative losses is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            },
            {
              "id": "B",
              "text": "Option C: A case-control odds ratio is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            },
            {
              "id": "C",
              "text": "Option D: A paired t test is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Kaplan-Meier analysis censoring deaths as ordinary noninformative losses is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A case-control odds ratio is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            },
            {
              "id": "B",
              "text": "Option B: Kaplan-Meier analysis censoring deaths as ordinary noninformative losses is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            },
            {
              "id": "C",
              "text": "Option D: A paired t test is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A case-control odds ratio is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A paired t test is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            },
            {
              "id": "B",
              "text": "Option B: Kaplan-Meier analysis censoring deaths as ordinary noninformative losses is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            },
            {
              "id": "C",
              "text": "Option C: A case-control odds ratio is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A paired t test is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Simple prevalence at enrollment is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            },
            {
              "id": "B",
              "text": "Option B: Kaplan-Meier analysis censoring deaths as ordinary noninformative losses is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            },
            {
              "id": "C",
              "text": "Option C: A case-control odds ratio is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Simple prevalence at enrollment is inappropriate because this choice does not address the decisive finding: death precludes future transplantation and is common. ordinary censoring assumes those censored retain the same future event opportunity."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-eclampsia-magnesium-delivery",
      "expectedHashes": {
        "ranaze_step3_uat": "627d7c1739b19f890170690a15b0be3571c51c8cabc9fbf7be5cefe9ca860083",
        "ranaze_step3_prd": "627d7c1739b19f890170690a15b0be3571c51c8cabc9fbf7be5cefe9ca860083"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer phenytoin and continue pregnancy to 39 weeks is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            },
            {
              "id": "B",
              "text": "Option C: Perform immediate cesarean delivery before maternal stabilization is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            },
            {
              "id": "C",
              "text": "Option D: Give diazepam as sole long-term therapy is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer phenytoin and continue pregnancy to 39 weeks is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate cesarean delivery before maternal stabilization is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            },
            {
              "id": "B",
              "text": "Option B: Administer phenytoin and continue pregnancy to 39 weeks is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            },
            {
              "id": "C",
              "text": "Option D: Give diazepam as sole long-term therapy is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate cesarean delivery before maternal stabilization is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give diazepam as sole long-term therapy is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            },
            {
              "id": "B",
              "text": "Option B: Administer phenytoin and continue pregnancy to 39 weeks is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            },
            {
              "id": "C",
              "text": "Option C: Perform immediate cesarean delivery before maternal stabilization is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give diazepam as sole long-term therapy is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe because the seizure has stopped is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            },
            {
              "id": "B",
              "text": "Option B: Administer phenytoin and continue pregnancy to 39 weeks is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            },
            {
              "id": "C",
              "text": "Option C: Perform immediate cesarean delivery before maternal stabilization is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe because the seizure has stopped is inappropriate because this choice does not address the decisive finding: new seizure with severe hypertension at 35 weeks. maternal stabilization precedes operative delivery."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-ectopic-pregnancy-fetal-cardiac-surgery",
      "expectedHashes": {
        "ranaze_step3_uat": "84ebdc9512155cb7549d183756414132d41204e68fe64281ceaddfccf91d883a",
        "ranaze_step3_prd": "84ebdc9512155cb7549d183756414132d41204e68fe64281ceaddfccf91d883a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Single-dose methotrexate is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            },
            {
              "id": "B",
              "text": "Option C: This choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            },
            {
              "id": "C",
              "text": "Option D: Dilation and curettage alone is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Single-dose methotrexate is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            },
            {
              "id": "B",
              "text": "Option B: Single-dose methotrexate is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            },
            {
              "id": "C",
              "text": "Option D: Dilation and curettage alone is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dilation and curettage alone is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            },
            {
              "id": "B",
              "text": "Option B: Single-dose methotrexate is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            },
            {
              "id": "C",
              "text": "Option C: This choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dilation and curettage alone is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat ultrasound in 4 weeks without precautions is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            },
            {
              "id": "B",
              "text": "Option B: Single-dose methotrexate is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            },
            {
              "id": "C",
              "text": "Option C: This choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat ultrasound in 4 weeks without precautions is inappropriate because this choice does not address the decisive finding: tubal ectopic pregnancy with fetal cardiac activity. expectant management is reserved for carefully selected resolving pregnancies."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-empyema-drainage-antibiotics",
      "expectedHashes": {
        "ranaze_step3_uat": "2e897ba0083881c74de250320203dfd9399f3231cc3b7199307d89a3224c71d8",
        "ranaze_step3_prd": "2e897ba0083881c74de250320203dfd9399f3231cc3b7199307d89a3224c71d8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue antibiotics alone is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            },
            {
              "id": "B",
              "text": "Option C: Repeat chest radiography in 6 weeks is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            },
            {
              "id": "C",
              "text": "Option D: Administer diuretics is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue antibiotics alone is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat chest radiography in 6 weeks is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            },
            {
              "id": "B",
              "text": "Option B: Continue antibiotics alone is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            },
            {
              "id": "C",
              "text": "Option D: Administer diuretics is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat chest radiography in 6 weeks is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer diuretics is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            },
            {
              "id": "B",
              "text": "Option B: Continue antibiotics alone is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            },
            {
              "id": "C",
              "text": "Option C: Repeat chest radiography in 6 weeks is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer diuretics is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform bronchoscopy without pleural drainage is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            },
            {
              "id": "B",
              "text": "Option B: Continue antibiotics alone is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            },
            {
              "id": "C",
              "text": "Option C: Repeat chest radiography in 6 weeks is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform bronchoscopy without pleural drainage is inappropriate because this choice does not address the decisive finding: frank pus with loculation, low pH, and organisms. diuresis does not treat pleural infection."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-ethylene-glycol-severe-poisoning-dialysis",
      "expectedHashes": {
        "ranaze_step3_uat": "f716e70b9a89798df837a7656225cae646c5e1bcd183797759ff7f26d29a3045",
        "ranaze_step3_prd": "f716e70b9a89798df837a7656225cae646c5e1bcd183797759ff7f26d29a3045"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous sodium thiosulfate is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            },
            {
              "id": "B",
              "text": "Option C: Activated charcoal alone is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            },
            {
              "id": "C",
              "text": "Option D: Urinary acidification is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous sodium thiosulfate is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Activated charcoal alone is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous sodium thiosulfate is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            },
            {
              "id": "C",
              "text": "Option D: Urinary acidification is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Activated charcoal alone is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urinary acidification is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous sodium thiosulfate is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            },
            {
              "id": "C",
              "text": "Option C: Activated charcoal alone is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urinary acidification is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation until the osmolar gap closes is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous sodium thiosulfate is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            },
            {
              "id": "C",
              "text": "Option C: Activated charcoal alone is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation until the osmolar gap closes is inappropriate because this choice does not address the decisive finding: progressive kidney injury and severe metabolic acidosis despite antidote. activated charcoal does not meaningfully bind toxic alcohols."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-febrile-infant-28-days-full-evaluation",
      "expectedHashes": {
        "ranaze_step3_uat": "28e0c799836679c65e296881e0970d6ec17527c2d85b9a3ca2401f4adcfe2d6c",
        "ranaze_step3_prd": "28e0c799836679c65e296881e0970d6ec17527c2d85b9a3ca2401f4adcfe2d6c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge after acetaminophen without testing is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            },
            {
              "id": "B",
              "text": "Option C: Obtain a chest radiograph only is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe oral amoxicillin without cultures is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge after acetaminophen without testing is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a chest radiograph only is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after acetaminophen without testing is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe oral amoxicillin without cultures is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a chest radiograph only is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe oral amoxicillin without cultures is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after acetaminophen without testing is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a chest radiograph only is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe oral amoxicillin without cultures is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer evaluation until fever lasts 48 hours is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after acetaminophen without testing is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a chest radiograph only is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer evaluation until fever lasts 48 hours is inappropriate because this choice does not address the decisive finding: documented fever in an 18-day-old without a source. antipyretic response does not exclude bacteremia or meningitis."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-febrile-neutropenia-immediate-antipseudomonal",
      "expectedHashes": {
        "ranaze_step3_uat": "196d776857827b5a3a142c0d7af4a53071d22ae36a61836bdaf8cbd67158ab93",
        "ranaze_step3_prd": "196d776857827b5a3a142c0d7af4a53071d22ae36a61836bdaf8cbd67158ab93"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for blood-culture growth before antibiotics is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            },
            {
              "id": "B",
              "text": "Option C: Oral azithromycin alone is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            },
            {
              "id": "C",
              "text": "Option D: Administer granulocyte transfusions routinely is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for blood-culture growth before antibiotics is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral azithromycin alone is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            },
            {
              "id": "B",
              "text": "Option B: Wait for blood-culture growth before antibiotics is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            },
            {
              "id": "C",
              "text": "Option D: Administer granulocyte transfusions routinely is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral azithromycin alone is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer granulocyte transfusions routinely is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            },
            {
              "id": "B",
              "text": "Option B: Wait for blood-culture growth before antibiotics is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            },
            {
              "id": "C",
              "text": "Option C: Oral azithromycin alone is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer granulocyte transfusions routinely is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge without treatment because no source is found is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            },
            {
              "id": "B",
              "text": "Option B: Wait for blood-culture growth before antibiotics is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            },
            {
              "id": "C",
              "text": "Option C: Oral azithromycin alone is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge without treatment because no source is found is inappropriate because this choice does not address the decisive finding: ANC 80/mm3 with expected prolonged neutropenia and fever. delaying antibiotics permits rapid progression of occult gram-negative infection."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-fournier-gangrene-immediate-debridement",
      "expectedHashes": {
        "ranaze_step3_uat": "bbec25d6f7a26d3da93b2799499cd93daa2e602d9cae561e31538a1c0e6fc0d9",
        "ranaze_step3_prd": "bbec25d6f7a26d3da93b2799499cd93daa2e602d9cae561e31538a1c0e6fc0d9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Needle aspiration of the scrotum is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            },
            {
              "id": "B",
              "text": "Option C: Topical antimicrobial therapy is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            },
            {
              "id": "C",
              "text": "Option D: Elective orchiectomy next week is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Needle aspiration of the scrotum is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical antimicrobial therapy is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            },
            {
              "id": "B",
              "text": "Option B: Needle aspiration of the scrotum is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            },
            {
              "id": "C",
              "text": "Option D: Elective orchiectomy next week is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical antimicrobial therapy is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elective orchiectomy next week is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            },
            {
              "id": "B",
              "text": "Option B: Needle aspiration of the scrotum is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            },
            {
              "id": "C",
              "text": "Option C: Topical antimicrobial therapy is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elective orchiectomy next week is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for wound-culture speciation is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            },
            {
              "id": "B",
              "text": "Option B: Needle aspiration of the scrotum is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            },
            {
              "id": "C",
              "text": "Option C: Topical antimicrobial therapy is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for wound-culture speciation is inappropriate because this choice does not address the decisive finding: perineal toxicity with fascial gas. antibiotics do not penetrate devitalized tissue adequately."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-gbs-respiratory-and-autonomic-monitoring",
      "expectedHashes": {
        "ranaze_step3_uat": "84c544280db3603de693989540e3d2d2dc262acf3a441161ce24e6bcab147284",
        "ranaze_step3_prd": "84c544280db3603de693989540e3d2d2dc262acf3a441161ce24e6bcab147284"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge after outpatient nerve conduction studies is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            },
            {
              "id": "B",
              "text": "Option C: Admit to an unmonitored rehabilitation unit is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            },
            {
              "id": "C",
              "text": "Option D: Begin glucocorticoids and reassess in one week is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge after outpatient nerve conduction studies is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Admit to an unmonitored rehabilitation unit is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after outpatient nerve conduction studies is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            },
            {
              "id": "C",
              "text": "Option D: Begin glucocorticoids and reassess in one week is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Admit to an unmonitored rehabilitation unit is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin glucocorticoids and reassess in one week is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after outpatient nerve conduction studies is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            },
            {
              "id": "C",
              "text": "Option C: Admit to an unmonitored rehabilitation unit is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin glucocorticoids and reassess in one week is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform lumbar puncture before any monitoring is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after outpatient nerve conduction studies is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            },
            {
              "id": "C",
              "text": "Option C: Admit to an unmonitored rehabilitation unit is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform lumbar puncture before any monitoring is inappropriate because this choice does not address the decisive finding: rapidly falling vital capacity with heart-rate and blood-pressure lability. glucocorticoids do not improve GBS outcomes."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-hhs-initial-fluid-resuscitation",
      "expectedHashes": {
        "ranaze_step3_uat": "ac447461a442b0a29ac8ccd506a82c922d2000c36d63f9a6c244bc24e984f2d3",
        "ranaze_step3_prd": "ac447461a442b0a29ac8ccd506a82c922d2000c36d63f9a6c244bc24e984f2d3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate bicarbonate infusion is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            },
            {
              "id": "B",
              "text": "Option C: Subcutaneous long-acting insulin only is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            },
            {
              "id": "C",
              "text": "Option D: Fluid restriction to prevent cerebral edema is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate bicarbonate infusion is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcutaneous long-acting insulin only is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            },
            {
              "id": "B",
              "text": "Option B: Immediate bicarbonate infusion is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            },
            {
              "id": "C",
              "text": "Option D: Fluid restriction to prevent cerebral edema is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcutaneous long-acting insulin only is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fluid restriction to prevent cerebral edema is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            },
            {
              "id": "B",
              "text": "Option B: Immediate bicarbonate infusion is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            },
            {
              "id": "C",
              "text": "Option C: Subcutaneous long-acting insulin only is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fluid restriction to prevent cerebral edema is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate hemodialysis is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            },
            {
              "id": "B",
              "text": "Option B: Immediate bicarbonate infusion is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            },
            {
              "id": "C",
              "text": "Option C: Subcutaneous long-acting insulin only is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate hemodialysis is inappropriate because this choice does not address the decisive finding: severe hyperosmolality and dehydration without acidosis. insulin before adequate volume assessment can worsen circulatory collapse."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-hit-stop-heparin-nonheparin-anticoagulant",
      "expectedHashes": {
        "ranaze_step3_uat": "8c567e4599b0a424a2032ac12515ac766aed4c1e5ba69e2e07da6a4e40149d10",
        "ranaze_step3_prd": "8c567e4599b0a424a2032ac12515ac766aed4c1e5ba69e2e07da6a4e40149d10"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop heparin and give no anticoagulation is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            },
            {
              "id": "B",
              "text": "Option C: Continue heparin while awaiting antibody tests is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            },
            {
              "id": "C",
              "text": "Option D: Begin warfarin alone immediately is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop heparin and give no anticoagulation is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue heparin while awaiting antibody tests is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            },
            {
              "id": "B",
              "text": "Option B: Stop heparin and give no anticoagulation is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            },
            {
              "id": "C",
              "text": "Option D: Begin warfarin alone immediately is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue heparin while awaiting antibody tests is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin warfarin alone immediately is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            },
            {
              "id": "B",
              "text": "Option B: Stop heparin and give no anticoagulation is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            },
            {
              "id": "C",
              "text": "Option C: Continue heparin while awaiting antibody tests is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin warfarin alone immediately is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give prophylactic platelet transfusions is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            },
            {
              "id": "B",
              "text": "Option B: Stop heparin and give no anticoagulation is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            },
            {
              "id": "C",
              "text": "Option C: Continue heparin while awaiting antibody tests is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give prophylactic platelet transfusions is inappropriate because this choice does not address the decisive finding: greater than 50% platelet fall on day 6 with new thrombosis. warfarin monotherapy before platelet recovery risks venous limb gangrene."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-hyperkalemia-ecg-calcium-first",
      "expectedHashes": {
        "ranaze_step3_uat": "2600401a2b383379a103cc68361fe8bfd6339dccf852b6baa172332f6fbe4cc8",
        "ranaze_step3_prd": "2600401a2b383379a103cc68361fe8bfd6339dccf852b6baa172332f6fbe4cc8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous regular insulin without dextrose is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            },
            {
              "id": "B",
              "text": "Option C: Nebulized albuterol alone is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            },
            {
              "id": "C",
              "text": "Option D: Oral sodium zirconium cyclosilicate is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous regular insulin without dextrose is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nebulized albuterol alone is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous regular insulin without dextrose is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            },
            {
              "id": "C",
              "text": "Option D: Oral sodium zirconium cyclosilicate is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nebulized albuterol alone is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral sodium zirconium cyclosilicate is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous regular insulin without dextrose is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            },
            {
              "id": "C",
              "text": "Option C: Nebulized albuterol alone is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral sodium zirconium cyclosilicate is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous furosemide is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous regular insulin without dextrose is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            },
            {
              "id": "C",
              "text": "Option C: Nebulized albuterol alone is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous furosemide is inappropriate because this choice does not address the decisive finding: potassium 7.2 mEq/L with QRS widening and absent P waves. calcium protects the myocardium but does not lower serum potassium."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-impaired-physician-patient-safety",
      "expectedHashes": {
        "ranaze_step3_uat": "c3f6fe5dfce46bd110ab3777bb300b9cbcdbebfa7cafe8e296dfffcd911e7ad5",
        "ranaze_step3_prd": "c3f6fe5dfce46bd110ab3777bb300b9cbcdbebfa7cafe8e296dfffcd911e7ad5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Allow the operation but document concerns afterward is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            },
            {
              "id": "B",
              "text": "Option C: Confront the surgeon privately after the case is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            },
            {
              "id": "C",
              "text": "Option D: Post the allegation on social media is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Allow the operation but document concerns afterward is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Confront the surgeon privately after the case is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            },
            {
              "id": "B",
              "text": "Option B: Allow the operation but document concerns afterward is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            },
            {
              "id": "C",
              "text": "Option D: Post the allegation on social media is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Confront the surgeon privately after the case is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Post the allegation on social media is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            },
            {
              "id": "B",
              "text": "Option B: Allow the operation but document concerns afterward is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            },
            {
              "id": "C",
              "text": "Option C: Confront the surgeon privately after the case is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Post the allegation on social media is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ignore the behavior because the surgeon is senior is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            },
            {
              "id": "B",
              "text": "Option B: Allow the operation but document concerns afterward is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            },
            {
              "id": "C",
              "text": "Option C: Confront the surgeon privately after the case is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ignore the behavior because the surgeon is senior is inappropriate because this choice does not address the decisive finding: objective signs of intoxication immediately before surgery. delayed private discussion does not protect the patient about to undergo anesthesia."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-intention-to-treat-crossover",
      "expectedHashes": {
        "ranaze_step3_uat": "cfef7acdee8808558f8386580b6b0907b6f1a952f703c600489c795a69f41ee2",
        "ranaze_step3_prd": "cfef7acdee8808558f8386580b6b0907b6f1a952f703c600489c795a69f41ee2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "According to treatment actually received is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            },
            {
              "id": "B",
              "text": "Option C: Exclude all crossover participants is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            },
            {
              "id": "C",
              "text": "Option D: According to the treatment preferred at enrollment is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "According to treatment actually received is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exclude all crossover participants is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            },
            {
              "id": "B",
              "text": "Option B: According to treatment actually received is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            },
            {
              "id": "C",
              "text": "Option D: According to the treatment preferred at enrollment is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exclude all crossover participants is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "According to the treatment preferred at enrollment is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            },
            {
              "id": "B",
              "text": "Option B: According to treatment actually received is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            },
            {
              "id": "C",
              "text": "Option C: Exclude all crossover participants is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "According to the treatment preferred at enrollment is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Include only participants with complete adherence is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            },
            {
              "id": "B",
              "text": "Option B: According to treatment actually received is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            },
            {
              "id": "C",
              "text": "Option C: Exclude all crossover participants is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Include only participants with complete adherence is inappropriate because this choice does not address the decisive finding: random treatment assignment followed by substantial crossover. per-protocol analysis can reintroduce selection bias."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-interaction-effect-modification-strata",
      "expectedHashes": {
        "ranaze_step3_uat": "77546cf3575403bdb23aa0b50aa0eba37bd86bdabf955ffaeeade4ba795d2eef",
        "ranaze_step3_prd": "77546cf3575403bdb23aa0b50aa0eba37bd86bdabf955ffaeeade4ba795d2eef"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            },
            {
              "id": "B",
              "text": "Option C: Selection bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            },
            {
              "id": "C",
              "text": "Option D: Lead-time bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Selection bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            },
            {
              "id": "B",
              "text": "Option B: This choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            },
            {
              "id": "C",
              "text": "Option D: Lead-time bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Selection bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lead-time bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            },
            {
              "id": "B",
              "text": "Option B: This choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            },
            {
              "id": "C",
              "text": "Option C: Selection bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lead-time bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Regression to the mean is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            },
            {
              "id": "B",
              "text": "Option B: This choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            },
            {
              "id": "C",
              "text": "Option C: Selection bias is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Regression to the mean is inappropriate because this choice does not address the decisive finding: markedly different randomized treatment effects across prespecified dependence strata. confounding distorts an effect because of imbalance rather than defining real heterogeneity."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-kawasaki-ivig-aspirin-echo",
      "expectedHashes": {
        "ranaze_step3_uat": "bd26327d55d3b16f7871219ecb35575dffcb3b7c46d825380aa952a52d8bc51d",
        "ranaze_step3_prd": "bd26327d55d3b16f7871219ecb35575dffcb3b7c46d825380aa952a52d8bc51d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral amoxicillin alone is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            },
            {
              "id": "B",
              "text": "Option C: Glucocorticoid cream and discharge is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            },
            {
              "id": "C",
              "text": "Option D: Delay treatment until coronary aneurysms appear is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral amoxicillin alone is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Glucocorticoid cream and discharge is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            },
            {
              "id": "B",
              "text": "Option B: Oral amoxicillin alone is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            },
            {
              "id": "C",
              "text": "Option D: Delay treatment until coronary aneurysms appear is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Glucocorticoid cream and discharge is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay treatment until coronary aneurysms appear is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            },
            {
              "id": "B",
              "text": "Option B: Oral amoxicillin alone is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            },
            {
              "id": "C",
              "text": "Option C: Glucocorticoid cream and discharge is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay treatment until coronary aneurysms appear is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Live-virus vaccination during intravenous immunoglobulin infusion is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            },
            {
              "id": "B",
              "text": "Option B: Oral amoxicillin alone is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            },
            {
              "id": "C",
              "text": "Option C: Glucocorticoid cream and discharge is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Live-virus vaccination during intravenous immunoglobulin infusion is inappropriate because this choice does not address the decisive finding: at least 5 days of fever with five principal mucocutaneous findings. treatment delay increases coronary risk."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-lupus-nephritis-proliferative-induction",
      "expectedHashes": {
        "ranaze_step3_uat": "95746a9a002147d56e62cf90a9ab6b1d7adc8ee53e45aa1ad87100fe2ddc0cfb",
        "ranaze_step3_prd": "95746a9a002147d56e62cf90a9ab6b1d7adc8ee53e45aa1ad87100fe2ddc0cfb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hydroxychloroquine alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            },
            {
              "id": "B",
              "text": "Option C: An ACE inhibitor alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            },
            {
              "id": "C",
              "text": "Option D: High-dose aspirin and observation is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hydroxychloroquine alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An ACE inhibitor alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            },
            {
              "id": "B",
              "text": "Option B: Hydroxychloroquine alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            },
            {
              "id": "C",
              "text": "Option D: High-dose aspirin and observation is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An ACE inhibitor alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose aspirin and observation is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            },
            {
              "id": "B",
              "text": "Option B: Hydroxychloroquine alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            },
            {
              "id": "C",
              "text": "Option C: An ACE inhibitor alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose aspirin and observation is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long-term dialysis without immunosuppression is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            },
            {
              "id": "B",
              "text": "Option B: Hydroxychloroquine alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            },
            {
              "id": "C",
              "text": "Option C: An ACE inhibitor alone is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long-term dialysis without immunosuppression is inappropriate because this choice does not address the decisive finding: class IV biopsy with active nephritic sediment and heavy proteinuria. ACE inhibition reduces proteinuria but does not control proliferative immune injury."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-massive-pe-systemic-thrombolysis",
      "expectedHashes": {
        "ranaze_step3_uat": "249a603d0e52f4653bea179c643769e1cf38020f9507e976effb6e5a4a5c0542",
        "ranaze_step3_prd": "249a603d0e52f4653bea179c643769e1cf38020f9507e976effb6e5a4a5c0542"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral apixaban and discharge is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            },
            {
              "id": "B",
              "text": "Option C: Inferior vena cava filter alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            },
            {
              "id": "C",
              "text": "Option D: Aspirin alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral apixaban and discharge is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inferior vena cava filter alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            },
            {
              "id": "B",
              "text": "Option B: Oral apixaban and discharge is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            },
            {
              "id": "C",
              "text": "Option D: Aspirin alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inferior vena cava filter alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspirin alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            },
            {
              "id": "B",
              "text": "Option B: Oral apixaban and discharge is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Inferior vena cava filter alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspirin alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay treatment for lower-extremity ultrasonography is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            },
            {
              "id": "B",
              "text": "Option B: Oral apixaban and discharge is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Inferior vena cava filter alone is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay treatment for lower-extremity ultrasonography is inappropriate because this choice does not address the decisive finding: persistent hypotension with severe right-ventricular strain from confirmed PE. stable PE is treated differently because thrombolysis carries major bleeding risk."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-medical-error-disclosure",
      "expectedHashes": {
        "ranaze_step3_uat": "cae9d92c19b72316e66224bbe65cb33c157534dc27292745167a7c942a100474",
        "ranaze_step3_prd": "cae9d92c19b72316e66224bbe65cb33c157534dc27292745167a7c942a100474"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait until the patient asks whether an error occurred is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            },
            {
              "id": "B",
              "text": "Option C: Describe the event only as an unpredictable allergic reaction is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            },
            {
              "id": "C",
              "text": "Option D: Ask risk management to speak while she avoids the patient is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait until the patient asks whether an error occurred is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Describe the event only as an unpredictable allergic reaction is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            },
            {
              "id": "B",
              "text": "Option B: Wait until the patient asks whether an error occurred is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            },
            {
              "id": "C",
              "text": "Option D: Ask risk management to speak while she avoids the patient is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Describe the event only as an unpredictable allergic reaction is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask risk management to speak while she avoids the patient is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            },
            {
              "id": "B",
              "text": "Option B: Wait until the patient asks whether an error occurred is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            },
            {
              "id": "C",
              "text": "Option C: Describe the event only as an unpredictable allergic reaction is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask risk management to speak while she avoids the patient is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alter the note to remove the allergy documentation is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            },
            {
              "id": "B",
              "text": "Option B: Wait until the patient asks whether an error occurred is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            },
            {
              "id": "C",
              "text": "Option C: Describe the event only as an unpredictable allergic reaction is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alter the note to remove the allergy documentation is inappropriate because this choice does not address the decisive finding: known preventable medication error with patient harm. concealment undermines autonomy, trust, and safety learning."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-meningococcal-exposure-rifampin-prophylaxis",
      "expectedHashes": {
        "ranaze_step3_uat": "ff3751778411b467707a5d517a0477eaa1ee938dcf1ed825b33d97121dcf8385",
        "ranaze_step3_prd": "ff3751778411b467707a5d517a0477eaa1ee938dcf1ed825b33d97121dcf8385"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No intervention because vaccination eliminates carriage risk is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            },
            {
              "id": "B",
              "text": "Option C: Wait for a throat culture result is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous ceftriaxone for 14 days is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No intervention because vaccination eliminates carriage risk is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for a throat culture result is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            },
            {
              "id": "B",
              "text": "Option B: No intervention because vaccination eliminates carriage risk is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            },
            {
              "id": "C",
              "text": "Option D: Administer intravenous ceftriaxone for 14 days is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for a throat culture result is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous ceftriaxone for 14 days is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            },
            {
              "id": "B",
              "text": "Option B: No intervention because vaccination eliminates carriage risk is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            },
            {
              "id": "C",
              "text": "Option C: Wait for a throat culture result is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous ceftriaxone for 14 days is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give immune globulin is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            },
            {
              "id": "B",
              "text": "Option B: No intervention because vaccination eliminates carriage risk is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            },
            {
              "id": "C",
              "text": "Option C: Wait for a throat culture result is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give immune globulin is inappropriate because this choice does not address the decisive finding: direct prolonged household and oral-secretion exposure during the infectious period. throat cultures do not guide whether close contacts receive prophylaxis."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-myasthenic-crisis-respiratory-failure",
      "expectedHashes": {
        "ranaze_step3_uat": "d0d8f2d141e1e30a754c140e80e2b06051ac2b6d52cec5fcabceea6e358661da",
        "ranaze_step3_prd": "d0d8f2d141e1e30a754c140e80e2b06051ac2b6d52cec5fcabceea6e358661da"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give pyridostigmine only and reassess in 4 hours is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            },
            {
              "id": "B",
              "text": "Option C: Administer supplemental oxygen without ventilatory support is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            },
            {
              "id": "C",
              "text": "Option D: Perform an edrophonium challenge is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give pyridostigmine only and reassess in 4 hours is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer supplemental oxygen without ventilatory support is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            },
            {
              "id": "B",
              "text": "Option B: Give pyridostigmine only and reassess in 4 hours is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            },
            {
              "id": "C",
              "text": "Option D: Perform an edrophonium challenge is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer supplemental oxygen without ventilatory support is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform an edrophonium challenge is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            },
            {
              "id": "B",
              "text": "Option B: Give pyridostigmine only and reassess in 4 hours is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            },
            {
              "id": "C",
              "text": "Option C: Administer supplemental oxygen without ventilatory support is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform an edrophonium challenge is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin noninvasive ventilation on an unmonitored ward is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            },
            {
              "id": "B",
              "text": "Option B: Give pyridostigmine only and reassess in 4 hours is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            },
            {
              "id": "C",
              "text": "Option C: Administer supplemental oxygen without ventilatory support is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin noninvasive ventilation on an unmonitored ward is inappropriate because this choice does not address the decisive finding: vital capacity 12 mL/kg with weak cough and dysphagia. edrophonium is diagnostic, not airway therapy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-myxedema-coma-steroids-before-thyroxine",
      "expectedHashes": {
        "ranaze_step3_uat": "bccd0e6d991f5fc3483c9b9c6c560067773e23c6311aa27ed4e603a1963b537f",
        "ranaze_step3_prd": "bccd0e6d991f5fc3483c9b9c6c560067773e23c6311aa27ed4e603a1963b537f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral levothyroxine after discharge is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous levothyroxine without glucocorticoids is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            },
            {
              "id": "C",
              "text": "Option D: Methimazole and propranolol is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral levothyroxine after discharge is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous levothyroxine without glucocorticoids is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            },
            {
              "id": "B",
              "text": "Option B: Oral levothyroxine after discharge is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            },
            {
              "id": "C",
              "text": "Option D: Methimazole and propranolol is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous levothyroxine without glucocorticoids is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Methimazole and propranolol is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            },
            {
              "id": "B",
              "text": "Option B: Oral levothyroxine after discharge is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous levothyroxine without glucocorticoids is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Methimazole and propranolol is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Rapid active external rewarming alone is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            },
            {
              "id": "B",
              "text": "Option B: Oral levothyroxine after discharge is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous levothyroxine without glucocorticoids is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Rapid active external rewarming alone is inappropriate because this choice does not address the decisive finding: hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism. oral therapy is unreliable in critical illness."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-necrotizing-fasciitis-surgical-source-control",
      "expectedHashes": {
        "ranaze_step3_uat": "15f544d2fff3ea915cf3d888cdaebdbe53f6a9ce832279a3a6e44ee113d096d0",
        "ranaze_step3_prd": "15f544d2fff3ea915cf3d888cdaebdbe53f6a9ce832279a3a6e44ee113d096d0"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI before surgical consultation is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            },
            {
              "id": "B",
              "text": "Option C: Bedside incision and drainage only is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            },
            {
              "id": "C",
              "text": "Option D: Hyperbaric oxygen as sole therapy is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI before surgical consultation is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bedside incision and drainage only is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            },
            {
              "id": "B",
              "text": "Option B: MRI before surgical consultation is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            },
            {
              "id": "C",
              "text": "Option D: Hyperbaric oxygen as sole therapy is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bedside incision and drainage only is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hyperbaric oxygen as sole therapy is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            },
            {
              "id": "B",
              "text": "Option B: MRI before surgical consultation is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            },
            {
              "id": "C",
              "text": "Option C: Bedside incision and drainage only is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hyperbaric oxygen as sole therapy is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe response to antibiotics for 12 hours is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            },
            {
              "id": "B",
              "text": "Option B: MRI before surgical consultation is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            },
            {
              "id": "C",
              "text": "Option C: Bedside incision and drainage only is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe response to antibiotics for 12 hours is inappropriate because this choice does not address the decisive finding: rapid progression with shock and violaceous bullae. antibiotics cannot replace debridement."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-noninferiority-trial-ci-interpretation",
      "expectedHashes": {
        "ranaze_step3_uat": "b83e8935e145f003051bee4b29905069dac4472d07396e27b5940db9add17181",
        "ranaze_step3_prd": "b83e8935e145f003051bee4b29905069dac4472d07396e27b5940db9add17181"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The shorter course is both noninferior and superior is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            },
            {
              "id": "B",
              "text": "Option C: Noninferiority is not established because the interval crosses zero is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            },
            {
              "id": "C",
              "text": "Option D: The treatments are proven equivalent is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The shorter course is both noninferior and superior is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Noninferiority is not established because the interval crosses zero is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            },
            {
              "id": "B",
              "text": "Option B: The shorter course is both noninferior and superior is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            },
            {
              "id": "C",
              "text": "Option D: The treatments are proven equivalent is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Noninferiority is not established because the interval crosses zero is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The treatments are proven equivalent is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            },
            {
              "id": "B",
              "text": "Option B: The shorter course is both noninferior and superior is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            },
            {
              "id": "C",
              "text": "Option C: Noninferiority is not established because the interval crosses zero is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The treatments are proven equivalent is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The standard course is superior because the point estimate is positive is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            },
            {
              "id": "B",
              "text": "Option B: The shorter course is both noninferior and superior is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            },
            {
              "id": "C",
              "text": "Option C: Noninferiority is not established because the interval crosses zero is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The standard course is superior because the point estimate is positive is inappropriate because this choice does not address the decisive finding: upper confidence bound \u002B4% is below the \u002B5% margin. crossing zero prevents superiority but not noninferiority."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-obstructed-infected-stone-decompression",
      "expectedHashes": {
        "ranaze_step3_uat": "58c9cc787323a76b1ed0ac41879e9e4b33fd3f036ba9201ce0aae49d5e1dbc88",
        "ranaze_step3_prd": "58c9cc787323a76b1ed0ac41879e9e4b33fd3f036ba9201ce0aae49d5e1dbc88"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Extracorporeal shock-wave lithotripsy immediately is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            },
            {
              "id": "B",
              "text": "Option C: Begin tamsulosin and outpatient follow-up is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            },
            {
              "id": "C",
              "text": "Option D: Wait for urine culture susceptibility results is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Extracorporeal shock-wave lithotripsy immediately is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin tamsulosin and outpatient follow-up is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            },
            {
              "id": "B",
              "text": "Option B: Extracorporeal shock-wave lithotripsy immediately is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            },
            {
              "id": "C",
              "text": "Option D: Wait for urine culture susceptibility results is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin tamsulosin and outpatient follow-up is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for urine culture susceptibility results is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            },
            {
              "id": "B",
              "text": "Option B: Extracorporeal shock-wave lithotripsy immediately is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            },
            {
              "id": "C",
              "text": "Option C: Begin tamsulosin and outpatient follow-up is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for urine culture susceptibility results is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase opioid analgesia only is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            },
            {
              "id": "B",
              "text": "Option B: Extracorporeal shock-wave lithotripsy immediately is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            },
            {
              "id": "C",
              "text": "Option C: Begin tamsulosin and outpatient follow-up is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase opioid analgesia only is inappropriate because this choice does not address the decisive finding: septic shock with hydronephrosis proximal to an obstructing stone. medical expulsive therapy is inappropriate in infected obstruction."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-ovarian-torsion-detorsion-preservation",
      "expectedHashes": {
        "ranaze_step3_uat": "55ed67fa18292e483d63c08fbfa36f2e599089f79686907a9b901e1e899bda94",
        "ranaze_step3_prd": "55ed67fa18292e483d63c08fbfa36f2e599089f79686907a9b901e1e899bda94"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oophorectomy because the ovary appears necrotic is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            },
            {
              "id": "B",
              "text": "Option C: Needle aspiration and discharge is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            },
            {
              "id": "C",
              "text": "Option D: Observe for return of Doppler flow is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oophorectomy because the ovary appears necrotic is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Needle aspiration and discharge is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            },
            {
              "id": "B",
              "text": "Option B: Oophorectomy because the ovary appears necrotic is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            },
            {
              "id": "C",
              "text": "Option D: Observe for return of Doppler flow is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Needle aspiration and discharge is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe for return of Doppler flow is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            },
            {
              "id": "B",
              "text": "Option B: Oophorectomy because the ovary appears necrotic is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            },
            {
              "id": "C",
              "text": "Option C: Needle aspiration and discharge is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe for return of Doppler flow is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin combined oral contraceptives only is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            },
            {
              "id": "B",
              "text": "Option B: Oophorectomy because the ovary appears necrotic is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            },
            {
              "id": "C",
              "text": "Option C: Needle aspiration and discharge is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin combined oral contraceptives only is inappropriate because this choice does not address the decisive finding: sudden pain, vomiting, enlarged ovary, and twisted pedicle. delay reduces ovarian salvage."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-pediatric-epiglottitis-controlled-airway",
      "expectedHashes": {
        "ranaze_step3_uat": "f4bffa3b45786881862b5e873aa78449c2a39eafb83ae12bbdbe72813f0fdefd",
        "ranaze_step3_prd": "f4bffa3b45786881862b5e873aa78449c2a39eafb83ae12bbdbe72813f0fdefd"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use a tongue depressor to inspect the pharynx immediately is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            },
            {
              "id": "B",
              "text": "Option C: Send the child alone for neck radiographs is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            },
            {
              "id": "C",
              "text": "Option D: Administer an oral antibiotic and discharge is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use a tongue depressor to inspect the pharynx immediately is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Send the child alone for neck radiographs is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            },
            {
              "id": "B",
              "text": "Option B: Use a tongue depressor to inspect the pharynx immediately is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            },
            {
              "id": "C",
              "text": "Option D: Administer an oral antibiotic and discharge is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Send the child alone for neck radiographs is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer an oral antibiotic and discharge is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            },
            {
              "id": "B",
              "text": "Option B: Use a tongue depressor to inspect the pharynx immediately is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            },
            {
              "id": "C",
              "text": "Option C: Send the child alone for neck radiographs is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer an oral antibiotic and discharge is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Force the child to lie supine for examination is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            },
            {
              "id": "B",
              "text": "Option B: Use a tongue depressor to inspect the pharynx immediately is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            },
            {
              "id": "C",
              "text": "Option C: Send the child alone for neck radiographs is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Force the child to lie supine for examination is inappropriate because this choice does not address the decisive finding: drooling, tripod posture, muffled voice, and stridor. forceful pharyngeal examination can trigger complete obstruction."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-pituitary-apoplexy-emergency-steroids",
      "expectedHashes": {
        "ranaze_step3_uat": "e1cd598061f670efc95ee91267c0121e0aec3576cb22ad12f3ea3dd450cfc516",
        "ranaze_step3_prd": "e1cd598061f670efc95ee91267c0121e0aec3576cb22ad12f3ea3dd450cfc516"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cabergoline is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            },
            {
              "id": "B",
              "text": "Option C: Levothyroxine before glucocorticoids is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            },
            {
              "id": "C",
              "text": "Option D: Mannitol is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cabergoline is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Levothyroxine before glucocorticoids is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            },
            {
              "id": "B",
              "text": "Option B: Cabergoline is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            },
            {
              "id": "C",
              "text": "Option D: Mannitol is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Levothyroxine before glucocorticoids is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mannitol is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            },
            {
              "id": "B",
              "text": "Option B: Cabergoline is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            },
            {
              "id": "C",
              "text": "Option C: Levothyroxine before glucocorticoids is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mannitol is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Emergent transsphenoidal surgery before medical stabilization is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            },
            {
              "id": "B",
              "text": "Option B: Cabergoline is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            },
            {
              "id": "C",
              "text": "Option C: Levothyroxine before glucocorticoids is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Emergent transsphenoidal surgery before medical stabilization is inappropriate because this choice does not address the decisive finding: sellar hemorrhage with hypotension and hypoglycemia. thyroid hormone can worsen untreated adrenal insufficiency."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-placenta-accreta-planned-cesarean-hysterectomy",
      "expectedHashes": {
        "ranaze_step3_uat": "e584d9a8c4054b661b0a5e6c2ec15d6f5e4cc51c90f54c5c7f448f60b32acf11",
        "ranaze_step3_prd": "e584d9a8c4054b661b0a5e6c2ec15d6f5e4cc51c90f54c5c7f448f60b32acf11"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Attempt manual placental removal after vaginal delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            },
            {
              "id": "B",
              "text": "Option C: Wait for spontaneous labor at 40 weeks is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            },
            {
              "id": "C",
              "text": "Option D: Perform dilation and curettage after cesarean delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Attempt manual placental removal after vaginal delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for spontaneous labor at 40 weeks is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            },
            {
              "id": "B",
              "text": "Option B: Attempt manual placental removal after vaginal delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            },
            {
              "id": "C",
              "text": "Option D: Perform dilation and curettage after cesarean delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for spontaneous labor at 40 weeks is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform dilation and curettage after cesarean delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            },
            {
              "id": "B",
              "text": "Option B: Attempt manual placental removal after vaginal delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            },
            {
              "id": "C",
              "text": "Option C: Wait for spontaneous labor at 40 weeks is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform dilation and curettage after cesarean delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give methotrexate before delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            },
            {
              "id": "B",
              "text": "Option B: Attempt manual placental removal after vaginal delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            },
            {
              "id": "C",
              "text": "Option C: Wait for spontaneous labor at 40 weeks is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give methotrexate before delivery is inappropriate because this choice does not address the decisive finding: previa plus multiple cesareans and accreta ultrasound signs. manual removal can cause massive bleeding."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-postpartum-endometritis-broad-spectrum-iv",
      "expectedHashes": {
        "ranaze_step3_uat": "2836c0083daa059833186cfcac718c2c59e7468379b2e0b4fbad933360e7b689",
        "ranaze_step3_prd": "2836c0083daa059833186cfcac718c2c59e7468379b2e0b4fbad933360e7b689"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral fluconazole is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            },
            {
              "id": "B",
              "text": "Option C: Immediate hysterectomy is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            },
            {
              "id": "C",
              "text": "Option D: Topical metronidazole only is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral fluconazole is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate hysterectomy is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            },
            {
              "id": "B",
              "text": "Option B: Oral fluconazole is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            },
            {
              "id": "C",
              "text": "Option D: Topical metronidazole only is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate hysterectomy is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical metronidazole only is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            },
            {
              "id": "B",
              "text": "Option B: Oral fluconazole is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            },
            {
              "id": "C",
              "text": "Option C: Immediate hysterectomy is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical metronidazole only is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation without antibiotics is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            },
            {
              "id": "B",
              "text": "Option B: Oral fluconazole is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            },
            {
              "id": "C",
              "text": "Option C: Immediate hysterectomy is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation without antibiotics is inappropriate because this choice does not address the decisive finding: fever with uterine tenderness and foul lochia after cesarean delivery. topical therapy does not treat an intrauterine infection."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-postpartum-hemorrhage-atony-escalation",
      "expectedHashes": {
        "ranaze_step3_uat": "efda72f782991c26dbbf3b40a459378a68609bf5805363a89d4d5e52e8b40d6a",
        "ranaze_step3_prd": "efda72f782991c26dbbf3b40a459378a68609bf5805363a89d4d5e52e8b40d6a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dilation and curettage despite a complete placenta is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            },
            {
              "id": "B",
              "text": "Option C: Immediate discharge after bleeding slows briefly is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            },
            {
              "id": "C",
              "text": "Option D: Methotrexate is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dilation and curettage despite a complete placenta is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate discharge after bleeding slows briefly is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            },
            {
              "id": "B",
              "text": "Option B: Dilation and curettage despite a complete placenta is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            },
            {
              "id": "C",
              "text": "Option D: Methotrexate is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate discharge after bleeding slows briefly is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Methotrexate is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            },
            {
              "id": "B",
              "text": "Option B: Dilation and curettage despite a complete placenta is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            },
            {
              "id": "C",
              "text": "Option C: Immediate discharge after bleeding slows briefly is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Methotrexate is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "External cephalic version is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            },
            {
              "id": "B",
              "text": "Option B: Dilation and curettage despite a complete placenta is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            },
            {
              "id": "C",
              "text": "Option C: Immediate discharge after bleeding slows briefly is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "External cephalic version is inappropriate because this choice does not address the decisive finding: continued atony bleeding despite massage and uterotonics with no retained placenta or laceration. curettage is directed at retained tissue, not isolated atony."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-postpartum-psychosis-emergency-hospitalization",
      "expectedHashes": {
        "ranaze_step3_uat": "3b3cc3afcc7a8f74d03e7c0564969de767f2b873ee89db29fb8326aacaa988c2",
        "ranaze_step3_prd": "3b3cc3afcc7a8f74d03e7c0564969de767f2b873ee89db29fb8326aacaa988c2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine outpatient psychotherapy next week is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            },
            {
              "id": "B",
              "text": "Option C: Reassurance that postpartum blues is self-limited is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            },
            {
              "id": "C",
              "text": "Option D: Start an SSRI and leave the infant in her care is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine outpatient psychotherapy next week is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassurance that postpartum blues is self-limited is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            },
            {
              "id": "B",
              "text": "Option B: Routine outpatient psychotherapy next week is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            },
            {
              "id": "C",
              "text": "Option D: Start an SSRI and leave the infant in her care is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassurance that postpartum blues is self-limited is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start an SSRI and leave the infant in her care is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            },
            {
              "id": "B",
              "text": "Option B: Routine outpatient psychotherapy next week is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            },
            {
              "id": "C",
              "text": "Option C: Reassurance that postpartum blues is self-limited is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start an SSRI and leave the infant in her care is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the family to monitor her at home is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            },
            {
              "id": "B",
              "text": "Option B: Routine outpatient psychotherapy next week is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            },
            {
              "id": "C",
              "text": "Option C: Reassurance that postpartum blues is self-limited is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the family to monitor her at home is inappropriate because this choice does not address the decisive finding: postpartum delusions with command hallucinations and mania. postpartum blues does not cause psychosis or dangerous commands."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-sentinel-event-root-cause-analysis",
      "expectedHashes": {
        "ranaze_step3_uat": "235dc41f641d171b06429a64da8314db0a7fb8280961e12d442cbc7addaf6bb1",
        "ranaze_step3_prd": "235dc41f641d171b06429a64da8314db0a7fb8280961e12d442cbc7addaf6bb1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Terminate the nurse and close the investigation is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            },
            {
              "id": "B",
              "text": "Option C: Remind all staff to be more careful is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            },
            {
              "id": "C",
              "text": "Option D: Wait to see whether the same event happens again is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Terminate the nurse and close the investigation is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remind all staff to be more careful is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            },
            {
              "id": "B",
              "text": "Option B: Terminate the nurse and close the investigation is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            },
            {
              "id": "C",
              "text": "Option D: Wait to see whether the same event happens again is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remind all staff to be more careful is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait to see whether the same event happens again is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            },
            {
              "id": "B",
              "text": "Option B: Terminate the nurse and close the investigation is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            },
            {
              "id": "C",
              "text": "Option C: Remind all staff to be more careful is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait to see whether the same event happens again is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Keep the event confidential from the safety office is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            },
            {
              "id": "B",
              "text": "Option B: Terminate the nurse and close the investigation is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            },
            {
              "id": "C",
              "text": "Option C: Remind all staff to be more careful is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Keep the event confidential from the safety office is inappropriate because this choice does not address the decisive finding: multiple interacting medication-system failures causing death or severe harm. punishment alone leaves look-alike stocking and downtime vulnerabilities intact."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-serotonin-syndrome-cyproheptadine",
      "expectedHashes": {
        "ranaze_step3_uat": "6feb5b4e08f6f3dae3f70a7bb2cd70c15d1480ca478ab1218eab3cf418ccf459",
        "ranaze_step3_prd": "6feb5b4e08f6f3dae3f70a7bb2cd70c15d1480ca478ab1218eab3cf418ccf459"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            },
            {
              "id": "B",
              "text": "Option C: Bromocriptine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            },
            {
              "id": "C",
              "text": "Option D: Physostigmine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bromocriptine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            },
            {
              "id": "B",
              "text": "Option B: This choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            },
            {
              "id": "C",
              "text": "Option D: Physostigmine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bromocriptine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Physostigmine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            },
            {
              "id": "B",
              "text": "Option B: This choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            },
            {
              "id": "C",
              "text": "Option C: Bromocriptine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Physostigmine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Haloperidol is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            },
            {
              "id": "B",
              "text": "Option B: This choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            },
            {
              "id": "C",
              "text": "Option C: Bromocriptine is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Haloperidol is inappropriate because this choice does not address the decisive finding: rapid onset with clonus after sertraline-linezolid interaction. dantrolene treats malignant hyperthermia, not serotonergic excess."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-severe-asthma-silent-chest-intubation",
      "expectedHashes": {
        "ranaze_step3_uat": "9fb6eb99e36993c212d5f95b7ee94030272335dc645438a2e17fe061e082ff1b",
        "ranaze_step3_prd": "9fb6eb99e36993c212d5f95b7ee94030272335dc645438a2e17fe061e082ff1b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue the same therapy for 6 more hours without airway preparation is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            },
            {
              "id": "B",
              "text": "Option C: Discharge with an inhaled corticosteroid is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            },
            {
              "id": "C",
              "text": "Option D: Administer a sedative and observe is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue the same therapy for 6 more hours without airway preparation is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with an inhaled corticosteroid is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            },
            {
              "id": "B",
              "text": "Option B: Continue the same therapy for 6 more hours without airway preparation is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            },
            {
              "id": "C",
              "text": "Option D: Administer a sedative and observe is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with an inhaled corticosteroid is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a sedative and observe is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            },
            {
              "id": "B",
              "text": "Option B: Continue the same therapy for 6 more hours without airway preparation is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            },
            {
              "id": "C",
              "text": "Option C: Discharge with an inhaled corticosteroid is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a sedative and observe is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform diagnostic bronchoscopy is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            },
            {
              "id": "B",
              "text": "Option B: Continue the same therapy for 6 more hours without airway preparation is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            },
            {
              "id": "C",
              "text": "Option C: Discharge with an inhaled corticosteroid is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform diagnostic bronchoscopy is inappropriate because this choice does not address the decisive finding: drowsiness, exhaustion, minimal air movement, and rising PCO2 despite maximal initial therapy. delayed intubation risks a peri-arrest crash airway."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-sjs-ten-immediate-drug-withdrawal",
      "expectedHashes": {
        "ranaze_step3_uat": "6972060ec7003a50a4cb824a1c6bec1149502ee2987f7f11e4cb69fe8a00814c",
        "ranaze_step3_prd": "6972060ec7003a50a4cb824a1c6bec1149502ee2987f7f11e4cb69fe8a00814c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue lamotrigine and add topical corticosteroids is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            },
            {
              "id": "B",
              "text": "Option C: Begin oral acyclovir is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            },
            {
              "id": "C",
              "text": "Option D: Debride all detached epidermis at bedside is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue lamotrigine and add topical corticosteroids is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin oral acyclovir is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            },
            {
              "id": "B",
              "text": "Option B: Continue lamotrigine and add topical corticosteroids is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            },
            {
              "id": "C",
              "text": "Option D: Debride all detached epidermis at bedside is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin oral acyclovir is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Debride all detached epidermis at bedside is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            },
            {
              "id": "B",
              "text": "Option B: Continue lamotrigine and add topical corticosteroids is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            },
            {
              "id": "C",
              "text": "Option C: Begin oral acyclovir is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Debride all detached epidermis at bedside is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with an oral antihistamine is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            },
            {
              "id": "B",
              "text": "Option B: Continue lamotrigine and add topical corticosteroids is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            },
            {
              "id": "C",
              "text": "Option C: Begin oral acyclovir is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with an oral antihistamine is inappropriate because this choice does not address the decisive finding: mucosal erosions with epidermal detachment after a high-risk drug. infection treatment does not replace drug withdrawal."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-spinal-epidural-abscess-urgent-mri",
      "expectedHashes": {
        "ranaze_step3_uat": "11d91e3f523689ae81ad17f6614463c37f462da3a25a9811f09ee0546f699633",
        "ranaze_step3_prd": "11d91e3f523689ae81ad17f6614463c37f462da3a25a9811f09ee0546f699633"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plain radiographs of the thoracic spine is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            },
            {
              "id": "B",
              "text": "Option C: Electromyography in 2 weeks is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            },
            {
              "id": "C",
              "text": "Option D: Lumbar puncture is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plain radiographs of the thoracic spine is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electromyography in 2 weeks is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the thoracic spine is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            },
            {
              "id": "C",
              "text": "Option D: Lumbar puncture is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electromyography in 2 weeks is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar puncture is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the thoracic spine is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            },
            {
              "id": "C",
              "text": "Option C: Electromyography in 2 weeks is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar puncture is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Noncontrast head CT is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the thoracic spine is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            },
            {
              "id": "C",
              "text": "Option C: Electromyography in 2 weeks is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Noncontrast head CT is inappropriate because this choice does not address the decisive finding: bacteremia plus focal back pain and an evolving sensory-motor level. plain films cannot exclude epidural infection or cord compression."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-status-epilepticus-second-line-therapy",
      "expectedHashes": {
        "ranaze_step3_uat": "46eae4f88d911d235df9e4526362872fbe5dcf938fecaaf0e4f1b773683e0448",
        "ranaze_step3_prd": "46eae4f88d911d235df9e4526362872fbe5dcf938fecaaf0e4f1b773683e0448"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Another hour of observation is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            },
            {
              "id": "B",
              "text": "Option C: Oral carbamazepine is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            },
            {
              "id": "C",
              "text": "Option D: Subcutaneous sumatriptan is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Another hour of observation is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral carbamazepine is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            },
            {
              "id": "B",
              "text": "Option B: Another hour of observation is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            },
            {
              "id": "C",
              "text": "Option D: Subcutaneous sumatriptan is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral carbamazepine is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcutaneous sumatriptan is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            },
            {
              "id": "B",
              "text": "Option B: Another hour of observation is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            },
            {
              "id": "C",
              "text": "Option C: Oral carbamazepine is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcutaneous sumatriptan is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intramuscular haloperidol is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            },
            {
              "id": "B",
              "text": "Option B: Another hour of observation is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            },
            {
              "id": "C",
              "text": "Option C: Oral carbamazepine is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intramuscular haloperidol is inappropriate because this choice does not address the decisive finding: ongoing convulsions after two adequate lorazepam doses. oral maintenance drugs are too slow for active status epilepticus."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-subarachnoid-hemorrhage-negative-ct-lp",
      "expectedHashes": {
        "ranaze_step3_uat": "afebcca4ebce4224ded1cc8b7244c75da1158a8e83865e413470c83e14fc43ac",
        "ranaze_step3_prd": "afebcca4ebce4224ded1cc8b7244c75da1158a8e83865e413470c83e14fc43ac"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with a migraine diagnosis is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            },
            {
              "id": "B",
              "text": "Option C: Electroencephalography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            },
            {
              "id": "C",
              "text": "Option D: Carotid duplex ultrasonography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with a migraine diagnosis is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electroencephalography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with a migraine diagnosis is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            },
            {
              "id": "C",
              "text": "Option D: Carotid duplex ultrasonography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electroencephalography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carotid duplex ultrasonography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with a migraine diagnosis is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            },
            {
              "id": "C",
              "text": "Option C: Electroencephalography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carotid duplex ultrasonography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat neurologic examination in one month is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with a migraine diagnosis is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            },
            {
              "id": "C",
              "text": "Option C: Electroencephalography is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat neurologic examination in one month is inappropriate because this choice does not address the decisive finding: classic thunderclap onset with CT performed 18 hours later. a normal examination does not exclude a sentinel subarachnoid bleed."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-surrogate-substituted-judgment",
      "expectedHashes": {
        "ranaze_step3_uat": "04a9e6022eb88f1f5a9b78fbf823a65b375cfe9bc21f622d4fdad1e5bb0b573e",
        "ranaze_step3_prd": "04a9e6022eb88f1f5a9b78fbf823a65b375cfe9bc21f622d4fdad1e5bb0b573e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The treatment the daughter would choose for herself is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            },
            {
              "id": "B",
              "text": "Option C: The least expensive treatment is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            },
            {
              "id": "C",
              "text": "Option D: The physician\u0027s personal moral preference is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The treatment the daughter would choose for herself is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The least expensive treatment is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            },
            {
              "id": "B",
              "text": "Option B: The treatment the daughter would choose for herself is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            },
            {
              "id": "C",
              "text": "Option D: The physician\u0027s personal moral preference is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The least expensive treatment is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The physician\u0027s personal moral preference is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            },
            {
              "id": "B",
              "text": "Option B: The treatment the daughter would choose for herself is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            },
            {
              "id": "C",
              "text": "Option C: The least expensive treatment is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The physician\u0027s personal moral preference is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Every available life-prolonging intervention regardless of prior wishes is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            },
            {
              "id": "B",
              "text": "Option B: The treatment the daughter would choose for herself is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            },
            {
              "id": "C",
              "text": "Option C: The least expensive treatment is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Every available life-prolonging intervention regardless of prior wishes is inappropriate because this choice does not address the decisive finding: specific prior statements addressing the current condition. oral statements and consistent values can still guide substituted judgment."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-ttp-immediate-plasma-exchange",
      "expectedHashes": {
        "ranaze_step3_uat": "0433c1c89f3779ba8226f1aad235c41c0a4e9c129ce74cf7ca158cc28c6e90ca",
        "ranaze_step3_prd": "0433c1c89f3779ba8226f1aad235c41c0a4e9c129ce74cf7ca158cc28c6e90ca"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Platelet transfusion alone is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            },
            {
              "id": "B",
              "text": "Option C: Vitamin K is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            },
            {
              "id": "C",
              "text": "Option D: Heparin infusion is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Platelet transfusion alone is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vitamin K is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            },
            {
              "id": "B",
              "text": "Option B: Platelet transfusion alone is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            },
            {
              "id": "C",
              "text": "Option D: Heparin infusion is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vitamin K is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Heparin infusion is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            },
            {
              "id": "B",
              "text": "Option B: Platelet transfusion alone is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            },
            {
              "id": "C",
              "text": "Option C: Vitamin K is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Heparin infusion is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for the ADAMTS13 result is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            },
            {
              "id": "B",
              "text": "Option B: Platelet transfusion alone is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            },
            {
              "id": "C",
              "text": "Option C: Vitamin K is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for the ADAMTS13 result is inappropriate because this choice does not address the decisive finding: schistocytic hemolysis with profound thrombocytopenia and normal coagulation tests. prophylactic platelet transfusion may worsen thrombosis and does not treat the mechanism."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-variceal-hemorrhage-antibiotics-octreotide",
      "expectedHashes": {
        "ranaze_step3_uat": "182fe4d3ac0aa03db51fd4a4075f77725a37810117a0f878a87d07f84cb0a594",
        "ranaze_step3_prd": "182fe4d3ac0aa03db51fd4a4075f77725a37810117a0f878a87d07f84cb0a594"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose aspirin and heparin is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            },
            {
              "id": "B",
              "text": "Option C: Oral propranolol alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            },
            {
              "id": "C",
              "text": "Option D: Vitamin K alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose aspirin and heparin is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral propranolol alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            },
            {
              "id": "B",
              "text": "Option B: High-dose aspirin and heparin is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            },
            {
              "id": "C",
              "text": "Option D: Vitamin K alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral propranolol alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vitamin K alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            },
            {
              "id": "B",
              "text": "Option B: High-dose aspirin and heparin is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            },
            {
              "id": "C",
              "text": "Option C: Oral propranolol alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vitamin K alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous metoclopramide alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            },
            {
              "id": "B",
              "text": "Option B: High-dose aspirin and heparin is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            },
            {
              "id": "C",
              "text": "Option C: Oral propranolol alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous metoclopramide alone is inappropriate because this choice does not address the decisive finding: cirrhosis with acute upper gastrointestinal hemorrhage awaiting endoscopy. nonselective beta blockers are for prevention and are not acute hemostatic therapy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-vasa-previa-fetal-hemorrhage",
      "expectedHashes": {
        "ranaze_step3_uat": "039777cc2933d43bda0f3c80cd5f0aa71ae852309921e45bf1dddfde51d65cd5",
        "ranaze_step3_prd": "039777cc2933d43bda0f3c80cd5f0aa71ae852309921e45bf1dddfde51d65cd5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal observation with repeat hemoglobin is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            },
            {
              "id": "B",
              "text": "Option C: Oxytocin augmentation for vaginal delivery is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            },
            {
              "id": "C",
              "text": "Option D: Digital examination for cervical dilation is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal observation with repeat hemoglobin is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oxytocin augmentation for vaginal delivery is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            },
            {
              "id": "B",
              "text": "Option B: Maternal observation with repeat hemoglobin is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            },
            {
              "id": "C",
              "text": "Option D: Digital examination for cervical dilation is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oxytocin augmentation for vaginal delivery is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Digital examination for cervical dilation is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            },
            {
              "id": "B",
              "text": "Option B: Maternal observation with repeat hemoglobin is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            },
            {
              "id": "C",
              "text": "Option C: Oxytocin augmentation for vaginal delivery is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Digital examination for cervical dilation is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer methotrexate is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            },
            {
              "id": "B",
              "text": "Option B: Maternal observation with repeat hemoglobin is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            },
            {
              "id": "C",
              "text": "Option C: Oxytocin augmentation for vaginal delivery is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer methotrexate is inappropriate because this choice does not address the decisive finding: bleeding after rupture with fetal bradycardia and velamentous insertion. expectant management risks fetal death."
        }
      }
    },
    {
      "externalId": "gap-d4-20260726-verification-bias-diagnostic-study",
      "expectedHashes": {
        "ranaze_step3_uat": "74ae6536faab9132858b613c5ce5fb7a1a7524c1359a35d3165e5276e8c580d7",
        "ranaze_step3_prd": "74ae6536faab9132858b613c5ce5fb7a1a7524c1359a35d3165e5276e8c580d7"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recall bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            },
            {
              "id": "B",
              "text": "Option C: Lead-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            },
            {
              "id": "C",
              "text": "Option D: Immortal-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recall bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lead-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            },
            {
              "id": "B",
              "text": "Option B: Recall bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            },
            {
              "id": "C",
              "text": "Option D: Immortal-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lead-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immortal-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            },
            {
              "id": "B",
              "text": "Option B: Recall bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            },
            {
              "id": "C",
              "text": "Option C: Lead-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immortal-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ecologic fallacy is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            },
            {
              "id": "B",
              "text": "Option B: Recall bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            },
            {
              "id": "C",
              "text": "Option C: Lead-time bias is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ecologic fallacy is inappropriate because this choice does not address the decisive finding: reference testing depends on index-test positivity. classifying unverified negatives as disease-free inflates apparent accuracy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-acute-angle-closure-immediate-pressure-lowering",
      "expectedHashes": {
        "ranaze_step3_uat": "0f3ed859e55228049f5d9c6d7a0cc91c16961f45d6f6833c8bed655e1edc307a",
        "ranaze_step3_prd": "0f3ed859e55228049f5d9c6d7a0cc91c16961f45d6f6833c8bed655e1edc307a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical antibiotic drops only does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            },
            {
              "id": "B",
              "text": "Option C: Eye patching and outpatient observation does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            },
            {
              "id": "C",
              "text": "Option D: Immediate cataract refraction does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical antibiotic drops only does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Eye patching and outpatient observation does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            },
            {
              "id": "B",
              "text": "Option B: Topical antibiotic drops only does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            },
            {
              "id": "C",
              "text": "Option D: Immediate cataract refraction does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Eye patching and outpatient observation does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate cataract refraction does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            },
            {
              "id": "B",
              "text": "Option B: Topical antibiotic drops only does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            },
            {
              "id": "C",
              "text": "Option C: Eye patching and outpatient observation does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate cataract refraction does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Systemic glucocorticoids alone does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            },
            {
              "id": "B",
              "text": "Option B: Topical antibiotic drops only does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            },
            {
              "id": "C",
              "text": "Option C: Eye patching and outpatient observation does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Systemic glucocorticoids alone does not adequately address the decisive finding: a fixed mid-dilated pupil. Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-acute-compartment-syndrome-fasciotomy",
      "expectedHashes": {
        "ranaze_step3_uat": "57a3e4af0766bcd5975e358bb8f666878b5e1f30b69e6dcd69f5aefa3a37a30b",
        "ranaze_step3_prd": "57a3e4af0766bcd5975e358bb8f666878b5e1f30b69e6dcd69f5aefa3a37a30b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT angiography of the leg does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "B",
              "text": "Option C: Elevation above heart level and observation does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "C",
              "text": "Option D: Increase opioid analgesia does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT angiography of the leg does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elevation above heart level and observation does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "B",
              "text": "Option B: CT angiography of the leg does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "C",
              "text": "Option D: Increase opioid analgesia does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elevation above heart level and observation does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase opioid analgesia does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "B",
              "text": "Option B: CT angiography of the leg does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "C",
              "text": "Option C: Elevation above heart level and observation does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase opioid analgesia does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for loss of pedal pulses does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "B",
              "text": "Option B: CT angiography of the leg does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "C",
              "text": "Option C: Elevation above heart level and observation does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for loss of pedal pulses does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serial creatine kinase measurement without decompression does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "B",
              "text": "Option B: CT angiography of the leg does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            },
            {
              "id": "C",
              "text": "Option C: Elevation above heart level and observation does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serial creatine kinase measurement without decompression does not adequately address the decisive finding: pain is severe with passive toe extension. Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-acute-leukemia-leukostasis-leukapheresis",
      "expectedHashes": {
        "ranaze_step3_uat": "5efa530fc4ec030053e586b0dc238ab62e0f0ac2769272ca16f1ea3f79242411",
        "ranaze_step3_prd": "5efa530fc4ec030053e586b0dc238ab62e0f0ac2769272ca16f1ea3f79242411"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Red-cell transfusion to raise viscosity does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            },
            {
              "id": "B",
              "text": "Option C: Observation until induction starts next week does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            },
            {
              "id": "C",
              "text": "Option D: Platelet inhibition alone does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Red-cell transfusion to raise viscosity does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation until induction starts next week does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            },
            {
              "id": "B",
              "text": "Option B: Red-cell transfusion to raise viscosity does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            },
            {
              "id": "C",
              "text": "Option D: Platelet inhibition alone does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation until induction starts next week does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Platelet inhibition alone does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            },
            {
              "id": "B",
              "text": "Option B: Red-cell transfusion to raise viscosity does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            },
            {
              "id": "C",
              "text": "Option C: Observation until induction starts next week does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Platelet inhibition alone does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Therapeutic anticoagulation does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            },
            {
              "id": "B",
              "text": "Option B: Red-cell transfusion to raise viscosity does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            },
            {
              "id": "C",
              "text": "Option C: Observation until induction starts next week does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Therapeutic anticoagulation does not adequately address the decisive finding: confusion. Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-acute-mesenteric-ischemia-cta",
      "expectedHashes": {
        "ranaze_step3_uat": "3e691c4d95f74fa5a97025dba0ed24595176eaac1b2aa160df2f9a723ad7266c",
        "ranaze_step3_prd": "3e691c4d95f74fa5a97025dba0ed24595176eaac1b2aa160df2f9a723ad7266c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine colonoscopy does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "B",
              "text": "Option C: Noncontrast abdominal radiography only does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "C",
              "text": "Option D: Barium enema does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine colonoscopy does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Noncontrast abdominal radiography only does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "B",
              "text": "Option B: Routine colonoscopy does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "C",
              "text": "Option D: Barium enema does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Noncontrast abdominal radiography only does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Barium enema does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "B",
              "text": "Option B: Routine colonoscopy does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "C",
              "text": "Option C: Noncontrast abdominal radiography only does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Barium enema does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elective magnetic resonance imaging next month does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "B",
              "text": "Option B: Routine colonoscopy does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "C",
              "text": "Option C: Noncontrast abdominal radiography only does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elective magnetic resonance imaging next month does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat lactate after analgesia before imaging does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "B",
              "text": "Option B: Routine colonoscopy does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            },
            {
              "id": "C",
              "text": "Option C: Noncontrast abdominal radiography only does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat lactate after analgesia before imaging does not adequately address the decisive finding: abrupt severe periumbilical pain. Obtain urgent CT angiography when acute mesenteric ischemia is suspected."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-acute-promyelocytic-leukemia-atra",
      "expectedHashes": {
        "ranaze_step3_uat": "83c0a50e4c3ecfb0262181b03f445aec095c41029c499645a992165a17693c93",
        "ranaze_step3_prd": "83c0a50e4c3ecfb0262181b03f445aec095c41029c499645a992165a17693c93"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for molecular confirmation before therapy does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "B",
              "text": "Option C: Warfarin does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "C",
              "text": "Option D: Platelet transfusion as the only treatment does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for molecular confirmation before therapy does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Warfarin does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "B",
              "text": "Option B: Wait for molecular confirmation before therapy does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "C",
              "text": "Option D: Platelet transfusion as the only treatment does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Warfarin does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Platelet transfusion as the only treatment does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "B",
              "text": "Option B: Wait for molecular confirmation before therapy does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "C",
              "text": "Option C: Warfarin does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Platelet transfusion as the only treatment does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Imatinib does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "B",
              "text": "Option B: Wait for molecular confirmation before therapy does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "C",
              "text": "Option C: Warfarin does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Imatinib does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay leukemia therapy until the coagulopathy resolves spontaneously does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "B",
              "text": "Option B: Wait for molecular confirmation before therapy does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            },
            {
              "id": "C",
              "text": "Option C: Warfarin does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay leukemia therapy until the coagulopathy resolves spontaneously does not adequately address the decisive finding: multiple Auer rods. Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-asplenia-vaccination-prevention",
      "expectedHashes": {
        "ranaze_step3_uat": "9a761bf5f7cf0a0af13cdc44da90ad75a768d8d12370eac6dec383d459ddd267",
        "ranaze_step3_prd": "9a761bf5f7cf0a0af13cdc44da90ad75a768d8d12370eac6dec383d459ddd267"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give no additional vaccines because childhood vaccination is complete does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            },
            {
              "id": "B",
              "text": "Option C: Wait until overwhelming sepsis occurs does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            },
            {
              "id": "C",
              "text": "Option D: Administer live oral polio vaccine does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give no additional vaccines because childhood vaccination is complete does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait until overwhelming sepsis occurs does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            },
            {
              "id": "B",
              "text": "Option B: Give no additional vaccines because childhood vaccination is complete does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            },
            {
              "id": "C",
              "text": "Option D: Administer live oral polio vaccine does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait until overwhelming sepsis occurs does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer live oral polio vaccine does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            },
            {
              "id": "B",
              "text": "Option B: Give no additional vaccines because childhood vaccination is complete does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            },
            {
              "id": "C",
              "text": "Option C: Wait until overwhelming sepsis occurs does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer live oral polio vaccine does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use antibiotics instead of all vaccines does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            },
            {
              "id": "B",
              "text": "Option B: Give no additional vaccines because childhood vaccination is complete does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            },
            {
              "id": "C",
              "text": "Option C: Wait until overwhelming sepsis occurs does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use antibiotics instead of all vaccines does not adequately address the decisive finding: scheduled for elective splenectomy. Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-basilar-artery-occlusion-thrombectomy",
      "expectedHashes": {
        "ranaze_step3_uat": "4cded266460b1010a54182b51683d6c0dd45f88b0690838cbeb2f74fa068464f",
        "ranaze_step3_prd": "4cded266460b1010a54182b51683d6c0dd45f88b0690838cbeb2f74fa068464f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspirin alone and routine ward admission does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            },
            {
              "id": "B",
              "text": "Option C: Delay treatment for repeat imaging tomorrow does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            },
            {
              "id": "C",
              "text": "Option D: Carotid endarterectomy does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspirin alone and routine ward admission does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay treatment for repeat imaging tomorrow does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            },
            {
              "id": "B",
              "text": "Option B: Aspirin alone and routine ward admission does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            },
            {
              "id": "C",
              "text": "Option D: Carotid endarterectomy does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay treatment for repeat imaging tomorrow does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carotid endarterectomy does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            },
            {
              "id": "B",
              "text": "Option B: Aspirin alone and routine ward admission does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            },
            {
              "id": "C",
              "text": "Option C: Delay treatment for repeat imaging tomorrow does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carotid endarterectomy does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar puncture does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            },
            {
              "id": "B",
              "text": "Option B: Aspirin alone and routine ward admission does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            },
            {
              "id": "C",
              "text": "Option C: Delay treatment for repeat imaging tomorrow does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar puncture does not adequately address the decisive finding: proximal basilar artery occlusion. Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-capacity-task-specific-assessment",
      "expectedHashes": {
        "ranaze_step3_uat": "7ee49ec5cb7f1b06ae0a762ba1778c72798d01c1cfd33ca2886d928ae1148205",
        "ranaze_step3_prd": "7ee49ec5cb7f1b06ae0a762ba1778c72798d01c1cfd33ca2886d928ae1148205"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Assume dementia eliminates capacity does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "B",
              "text": "Option C: Let the daughter decide because she disagrees does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "C",
              "text": "Option D: Seek a court order solely because the choice is risky does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Assume dementia eliminates capacity does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Let the daughter decide because she disagrees does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "B",
              "text": "Option B: Assume dementia eliminates capacity does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "C",
              "text": "Option D: Seek a court order solely because the choice is risky does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Let the daughter decide because she disagrees does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Seek a court order solely because the choice is risky does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "B",
              "text": "Option B: Assume dementia eliminates capacity does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "C",
              "text": "Option C: Let the daughter decide because she disagrees does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Seek a court order solely because the choice is risky does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sedate the patient and operate does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "B",
              "text": "Option B: Assume dementia eliminates capacity does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "C",
              "text": "Option C: Let the daughter decide because she disagrees does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sedate the patient and operate does not adequately address the decisive finding: he clearly explains that surgery could prevent death. Respect a capable patient\u0027s informed refusal even when clinicians or family strongly disagree."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-cardiac-tamponade-urgent-drainage",
      "expectedHashes": {
        "ranaze_step3_uat": "d34ab26e4fc4e2b73bc646ad8605205958e22b6bb8730d49ab4597292d1af476",
        "ranaze_step3_prd": "d34ab26e4fc4e2b73bc646ad8605205958e22b6bb8730d49ab4597292d1af476"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aggressive diuresis does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "B",
              "text": "Option C: Positive-pressure ventilation before drainage does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "C",
              "text": "Option D: Observation with repeat imaging next week does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aggressive diuresis does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Positive-pressure ventilation before drainage does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "B",
              "text": "Option B: Aggressive diuresis does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "C",
              "text": "Option D: Observation with repeat imaging next week does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Positive-pressure ventilation before drainage does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation with repeat imaging next week does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "B",
              "text": "Option B: Aggressive diuresis does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "C",
              "text": "Option C: Positive-pressure ventilation before drainage does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation with repeat imaging next week does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Systemic thrombolysis does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "B",
              "text": "Option B: Aggressive diuresis does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "C",
              "text": "Option C: Positive-pressure ventilation before drainage does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Systemic thrombolysis does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase beta-blocker therapy does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "B",
              "text": "Option B: Aggressive diuresis does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            },
            {
              "id": "C",
              "text": "Option C: Positive-pressure ventilation before drainage does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase beta-blocker therapy does not adequately address the decisive finding: right-ventricular diastolic collapse. Drain the pericardium urgently when tamponade causes hemodynamic instability."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-catatonia-lorazepam-challenge",
      "expectedHashes": {
        "ranaze_step3_uat": "2b2d207bcf23a38100e4059c5a2618cf4bd9cadd2d8418f7ff2ce89e18d7928c",
        "ranaze_step3_prd": "2b2d207bcf23a38100e4059c5a2618cf4bd9cadd2d8418f7ff2ce89e18d7928c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-potency antipsychotic escalation does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "B",
              "text": "Option C: Physical restraints as definitive therapy does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "C",
              "text": "Option D: Dopamine agonist for Parkinson disease does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-potency antipsychotic escalation does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Physical restraints as definitive therapy does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "B",
              "text": "Option B: High-potency antipsychotic escalation does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "C",
              "text": "Option D: Dopamine agonist for Parkinson disease does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Physical restraints as definitive therapy does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dopamine agonist for Parkinson disease does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "B",
              "text": "Option B: High-potency antipsychotic escalation does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "C",
              "text": "Option C: Physical restraints as definitive therapy does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dopamine agonist for Parkinson disease does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge without treatment does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "B",
              "text": "Option B: High-potency antipsychotic escalation does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "C",
              "text": "Option C: Physical restraints as definitive therapy does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge without treatment does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Supportive observation until spontaneous movement returns does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "B",
              "text": "Option B: High-potency antipsychotic escalation does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            },
            {
              "id": "C",
              "text": "Option C: Physical restraints as definitive therapy does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Supportive observation until spontaneous movement returns does not adequately address the decisive finding: she maintains imposed postures. Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-cauda-equina-urgent-decompression",
      "expectedHashes": {
        "ranaze_step3_uat": "c09c385596ac902e4567c359e089621b41b6922c23db650f3e7ba8db2be00030",
        "ranaze_step3_prd": "c09c385596ac902e4567c359e089621b41b6922c23db650f3e7ba8db2be00030"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine outpatient physical therapy does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "B",
              "text": "Option C: Lumbar epidural steroid injection before imaging does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "C",
              "text": "Option D: Oral analgesics with follow-up in one month does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine outpatient physical therapy does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar epidural steroid injection before imaging does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "B",
              "text": "Option B: Routine outpatient physical therapy does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "C",
              "text": "Option D: Oral analgesics with follow-up in one month does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar epidural steroid injection before imaging does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral analgesics with follow-up in one month does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "B",
              "text": "Option B: Routine outpatient physical therapy does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar epidural steroid injection before imaging does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral analgesics with follow-up in one month does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electromyography before spinal imaging does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "B",
              "text": "Option B: Routine outpatient physical therapy does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar epidural steroid injection before imaging does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electromyography before spinal imaging does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bladder training before evaluating the spinal canal does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "B",
              "text": "Option B: Routine outpatient physical therapy does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar epidural steroid injection before imaging does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bladder training before evaluating the spinal canal does not adequately address the decisive finding: he cannot initiate urination. Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-cerebral-venous-thrombosis-anticoagulation",
      "expectedHashes": {
        "ranaze_step3_uat": "6a4511c35b506c38f5b680e4758053532cdaaec8ccc4b50be9d0bff8e6357840",
        "ranaze_step3_prd": "6a4511c35b506c38f5b680e4758053532cdaaec8ccc4b50be9d0bff8e6357840"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold anticoagulation because any intracranial blood is present does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "B",
              "text": "Option C: Aspirin only does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "C",
              "text": "Option D: Immediate carotid endarterectomy does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold anticoagulation because any intracranial blood is present does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspirin only does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "B",
              "text": "Option B: Withhold anticoagulation because any intracranial blood is present does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "C",
              "text": "Option D: Immediate carotid endarterectomy does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspirin only does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate carotid endarterectomy does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "B",
              "text": "Option B: Withhold anticoagulation because any intracranial blood is present does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "C",
              "text": "Option C: Aspirin only does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate carotid endarterectomy does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Glucocorticoids alone does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "B",
              "text": "Option B: Withhold anticoagulation because any intracranial blood is present does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "C",
              "text": "Option C: Aspirin only does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Glucocorticoids alone does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat the seizure without addressing the thrombosis does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "B",
              "text": "Option B: Withhold anticoagulation because any intracranial blood is present does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            },
            {
              "id": "C",
              "text": "Option C: Aspirin only does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat the seizure without addressing the thrombosis does not adequately address the decisive finding: superior sagittal sinus thrombosis. Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-chemical-eye-injury-immediate-irrigation",
      "expectedHashes": {
        "ranaze_step3_uat": "7b85a40d20b904df88a38942939c23bbc827f707313874602ea51a1ca0dd156f",
        "ranaze_step3_prd": "7b85a40d20b904df88a38942939c23bbc827f707313874602ea51a1ca0dd156f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure visual acuity before any treatment does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "B",
              "text": "Option C: Neutralize the alkali with an acid does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "C",
              "text": "Option D: Wait for an ophthalmologist before irrigation does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure visual acuity before any treatment does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neutralize the alkali with an acid does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "B",
              "text": "Option B: Measure visual acuity before any treatment does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "C",
              "text": "Option D: Wait for an ophthalmologist before irrigation does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neutralize the alkali with an acid does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for an ophthalmologist before irrigation does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "B",
              "text": "Option B: Measure visual acuity before any treatment does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "C",
              "text": "Option C: Neutralize the alkali with an acid does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for an ophthalmologist before irrigation does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply topical anesthetic and discharge does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "B",
              "text": "Option B: Measure visual acuity before any treatment does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "C",
              "text": "Option C: Neutralize the alkali with an acid does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply topical anesthetic and discharge does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cover both eyes until the product safety sheet is reviewed does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "B",
              "text": "Option B: Measure visual acuity before any treatment does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            },
            {
              "id": "C",
              "text": "Option C: Neutralize the alkali with an acid does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cover both eyes until the product safety sheet is reviewed does not adequately address the decisive finding: an alkaline cleaning solution. Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-child-abuse-sentinel-injury-evaluation",
      "expectedHashes": {
        "ranaze_step3_uat": "7e93fcd6204779fdb782246732388e3dfccab3760288e211a82afb828c541a29",
        "ranaze_step3_prd": "7e93fcd6204779fdb782246732388e3dfccab3760288e211a82afb828c541a29"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge because the bruise is small does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "B",
              "text": "Option C: Wait for another injury before reporting concern does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "C",
              "text": "Option D: Confront the caregiver and permit departure does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge because the bruise is small does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for another injury before reporting concern does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "B",
              "text": "Option B: Discharge because the bruise is small does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "C",
              "text": "Option D: Confront the caregiver and permit departure does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for another injury before reporting concern does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Confront the caregiver and permit departure does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "B",
              "text": "Option B: Discharge because the bruise is small does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "C",
              "text": "Option C: Wait for another injury before reporting concern does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Confront the caregiver and permit departure does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Document only the current bruise does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "B",
              "text": "Option B: Discharge because the bruise is small does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "C",
              "text": "Option C: Wait for another injury before reporting concern does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Document only the current bruise does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the caregiver to arrange outpatient skeletal imaging does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "B",
              "text": "Option B: Discharge because the bruise is small does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "C",
              "text": "Option C: Wait for another injury before reporting concern does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the caregiver to arrange outpatient skeletal imaging does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Report only if the caregiver confesses does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "B",
              "text": "Option B: Discharge because the bruise is small does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            },
            {
              "id": "C",
              "text": "Option C: Wait for another injury before reporting concern does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Report only if the caregiver confesses does not adequately address the decisive finding: a small bruise on the cheek. Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-cryptococcal-meningitis-raised-pressure",
      "expectedHashes": {
        "ranaze_step3_uat": "2680b8af340341e8376a5afe8c69d71e48d82f52df8cd55b9baf6a75a4994aff",
        "ranaze_step3_prd": "2680b8af340341e8376a5afe8c69d71e48d82f52df8cd55b9baf6a75a4994aff"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acetazolamide as sole therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "B",
              "text": "Option C: Routine glucocorticoids does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "C",
              "text": "Option D: Stop antifungal therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acetazolamide as sole therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine glucocorticoids does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "B",
              "text": "Option B: Acetazolamide as sole therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "C",
              "text": "Option D: Stop antifungal therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine glucocorticoids does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop antifungal therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "B",
              "text": "Option B: Acetazolamide as sole therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "C",
              "text": "Option C: Routine glucocorticoids does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop antifungal therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place a permanent shunt before attempting serial drainage does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "B",
              "text": "Option B: Acetazolamide as sole therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "C",
              "text": "Option C: Routine glucocorticoids does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place a permanent shunt before attempting serial drainage does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mannitol without cerebrospinal-fluid drainage does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "B",
              "text": "Option B: Acetazolamide as sole therapy does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            },
            {
              "id": "C",
              "text": "Option C: Routine glucocorticoids does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mannitol without cerebrospinal-fluid drainage does not adequately address the decisive finding: markedly elevated opening pressure. Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-dermatomyositis-malignancy-screening",
      "expectedHashes": {
        "ranaze_step3_uat": "a1ebf83bd7148f96b4ca0794c566ffae63114e2e3a4dda6780ee21296a742ed5",
        "ranaze_step3_prd": "a1ebf83bd7148f96b4ca0794c566ffae63114e2e3a4dda6780ee21296a742ed5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Testing only for Lyme disease does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "B",
              "text": "Option C: Immediate muscle biopsy before any cancer evaluation does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "C",
              "text": "Option D: Reassurance that the condition is never paraneoplastic does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Testing only for Lyme disease does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate muscle biopsy before any cancer evaluation does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "B",
              "text": "Option B: Testing only for Lyme disease does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "C",
              "text": "Option D: Reassurance that the condition is never paraneoplastic does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate muscle biopsy before any cancer evaluation does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassurance that the condition is never paraneoplastic does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "B",
              "text": "Option B: Testing only for Lyme disease does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "C",
              "text": "Option C: Immediate muscle biopsy before any cancer evaluation does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassurance that the condition is never paraneoplastic does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long-term antibiotics for presumed cellulitis does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "B",
              "text": "Option B: Testing only for Lyme disease does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "C",
              "text": "Option C: Immediate muscle biopsy before any cancer evaluation does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long-term antibiotics for presumed cellulitis does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat electromyography yearly without age-appropriate screening does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "B",
              "text": "Option B: Testing only for Lyme disease does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            },
            {
              "id": "C",
              "text": "Option C: Immediate muscle biopsy before any cancer evaluation does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat electromyography yearly without age-appropriate screening does not adequately address the decisive finding: progressive proximal weakness. Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-diabetic-foot-osteomyelitis-bone-culture",
      "expectedHashes": {
        "ranaze_step3_uat": "07fb57ea2f5aaea28a76807a39fdd5c95a6925471b435ea6830ab1d8a749597f",
        "ranaze_step3_prd": "07fb57ea2f5aaea28a76807a39fdd5c95a6925471b435ea6830ab1d8a749597f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat superficial swab culture does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "B",
              "text": "Option C: Serum procalcitonin alone does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "C",
              "text": "Option D: Blood culture after antibiotics does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat superficial swab culture does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum procalcitonin alone does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "B",
              "text": "Option B: Repeat superficial swab culture does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "C",
              "text": "Option D: Blood culture after antibiotics does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum procalcitonin alone does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Blood culture after antibiotics does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "B",
              "text": "Option B: Repeat superficial swab culture does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "C",
              "text": "Option C: Serum procalcitonin alone does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Blood culture after antibiotics does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tagged leukocyte scan without tissue sampling does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "B",
              "text": "Option B: Repeat superficial swab culture does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "C",
              "text": "Option C: Serum procalcitonin alone does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tagged leukocyte scan without tissue sampling does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Empiric lifelong antibiotics without microbiologic sampling does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "B",
              "text": "Option B: Repeat superficial swab culture does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            },
            {
              "id": "C",
              "text": "Option C: Serum procalcitonin alone does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Empiric lifelong antibiotics without microbiologic sampling does not adequately address the decisive finding: probes to bone. Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-lithium-toxicity-hemodialysis",
      "expectedHashes": {
        "ranaze_step3_uat": "bc35457893d8af5670a08f1441309a3c0ebf2b67fff33063f749cf7d0d607071",
        "ranaze_step3_prd": "bc35457893d8af5670a08f1441309a3c0ebf2b67fff33063f749cf7d0d607071"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Activated charcoal does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "B",
              "text": "Option C: Restart lithium at a lower dose does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "C",
              "text": "Option D: Urinary alkalinization does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Activated charcoal does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restart lithium at a lower dose does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "B",
              "text": "Option B: Activated charcoal does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "C",
              "text": "Option D: Urinary alkalinization does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restart lithium at a lower dose does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urinary alkalinization does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "B",
              "text": "Option B: Activated charcoal does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "C",
              "text": "Option C: Restart lithium at a lower dose does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urinary alkalinization does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Flumazenil does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "B",
              "text": "Option B: Activated charcoal does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "C",
              "text": "Option C: Restart lithium at a lower dose does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Flumazenil does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whole-bowel irrigation as definitive therapy does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "B",
              "text": "Option B: Activated charcoal does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            },
            {
              "id": "C",
              "text": "Option C: Restart lithium at a lower dose does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whole-bowel irrigation as definitive therapy does not adequately address the decisive finding: repeated seizures. Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-malignancy-hypercalcemia-calcitonin-bisphosphonate",
      "expectedHashes": {
        "ranaze_step3_uat": "8d6b3df67cbbc84367aeea15063f1852239ee19446670cdfd8e850f51426d976",
        "ranaze_step3_prd": "8d6b3df67cbbc84367aeea15063f1852239ee19446670cdfd8e850f51426d976"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thiazide diuretic does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            },
            {
              "id": "B",
              "text": "Option C: Vitamin D supplementation does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            },
            {
              "id": "C",
              "text": "Option D: Observation after fluids only does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thiazide diuretic does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vitamin D supplementation does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            },
            {
              "id": "B",
              "text": "Option B: Thiazide diuretic does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            },
            {
              "id": "C",
              "text": "Option D: Observation after fluids only does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vitamin D supplementation does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation after fluids only does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            },
            {
              "id": "B",
              "text": "Option B: Thiazide diuretic does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            },
            {
              "id": "C",
              "text": "Option C: Vitamin D supplementation does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation after fluids only does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Teriparatide does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            },
            {
              "id": "B",
              "text": "Option B: Thiazide diuretic does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            },
            {
              "id": "C",
              "text": "Option C: Vitamin D supplementation does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Teriparatide does not adequately address the decisive finding: severe symptomatic hypercalcemia. Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-malignant-spinal-cord-compression",
      "expectedHashes": {
        "ranaze_step3_uat": "456c0185d7bba90ac052b90f63bee71b14ec60d9b828726691ac7d46aaf94f71",
        "ranaze_step3_prd": "456c0185d7bba90ac052b90f63bee71b14ec60d9b828726691ac7d46aaf94f71"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule routine radiographs next week does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "B",
              "text": "Option C: Perform lumbar puncture does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "C",
              "text": "Option D: Start physical therapy only does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule routine radiographs next week does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform lumbar puncture does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "B",
              "text": "Option B: Schedule routine radiographs next week does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "C",
              "text": "Option D: Start physical therapy only does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform lumbar puncture does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start physical therapy only does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "B",
              "text": "Option B: Schedule routine radiographs next week does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "C",
              "text": "Option C: Perform lumbar puncture does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start physical therapy only does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for complete paralysis before imaging does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "B",
              "text": "Option B: Schedule routine radiographs next week does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "C",
              "text": "Option C: Perform lumbar puncture does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for complete paralysis before imaging does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a bone scan before treating cord compression does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "B",
              "text": "Option B: Schedule routine radiographs next week does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            },
            {
              "id": "C",
              "text": "Option C: Perform lumbar puncture does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a bone scan before treating cord compression does not adequately address the decisive finding: progressive leg weakness. Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-meningitis-dexamethasone-before-antibiotics",
      "expectedHashes": {
        "ranaze_step3_uat": "f175e0016b56757b3f41fae853626e00647dd61646c0d2aee53ea0167fa72c5b",
        "ranaze_step3_prd": "f175e0016b56757b3f41fae853626e00647dd61646c0d2aee53ea0167fa72c5b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acyclovir as the only antimicrobial does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            },
            {
              "id": "B",
              "text": "Option C: Mannitol routinely does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            },
            {
              "id": "C",
              "text": "Option D: Therapeutic heparin does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acyclovir as the only antimicrobial does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mannitol routinely does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            },
            {
              "id": "B",
              "text": "Option B: Acyclovir as the only antimicrobial does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            },
            {
              "id": "C",
              "text": "Option D: Therapeutic heparin does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mannitol routinely does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Therapeutic heparin does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            },
            {
              "id": "B",
              "text": "Option B: Acyclovir as the only antimicrobial does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            },
            {
              "id": "C",
              "text": "Option C: Mannitol routinely does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Therapeutic heparin does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay all treatment until lumbar puncture does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            },
            {
              "id": "B",
              "text": "Option B: Acyclovir as the only antimicrobial does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            },
            {
              "id": "C",
              "text": "Option C: Mannitol routinely does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay all treatment until lumbar puncture does not adequately address the decisive finding: neck stiffness. Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-native-septic-arthritis-drainage",
      "expectedHashes": {
        "ranaze_step3_uat": "41f51c6049773505e19452078b04aa378ec415e4a7ae292d96812b2c9babfdd1",
        "ranaze_step3_prd": "41f51c6049773505e19452078b04aa378ec415e4a7ae292d96812b2c9babfdd1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intra-articular glucocorticoid injection does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "B",
              "text": "Option C: Oral colchicine alone does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "C",
              "text": "Option D: Delay treatment for final culture susceptibilities does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intra-articular glucocorticoid injection does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral colchicine alone does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "B",
              "text": "Option B: Intra-articular glucocorticoid injection does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "C",
              "text": "Option D: Delay treatment for final culture susceptibilities does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral colchicine alone does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay treatment for final culture susceptibilities does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "B",
              "text": "Option B: Intra-articular glucocorticoid injection does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "C",
              "text": "Option C: Oral colchicine alone does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay treatment for final culture susceptibilities does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Physical therapy without antimicrobial treatment does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "B",
              "text": "Option B: Intra-articular glucocorticoid injection does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "C",
              "text": "Option C: Oral colchicine alone does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Physical therapy without antimicrobial treatment does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arthroscopic inspection without drainage or antibiotics does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "B",
              "text": "Option B: Intra-articular glucocorticoid injection does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            },
            {
              "id": "C",
              "text": "Option C: Oral colchicine alone does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arthroscopic inspection without drainage or antibiotics does not adequately address the decisive finding: arthrocentesis yields opaque fluid with gram-positive cocci. Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-neonatal-bilious-emesis-volvulus",
      "expectedHashes": {
        "ranaze_step3_uat": "70369badac2925b81e55184624af4936f23d5d3194d60149bfe2c8488f2ab5ad",
        "ranaze_step3_prd": "70369badac2925b81e55184624af4936f23d5d3194d60149bfe2c8488f2ab5ad"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge after changing formula does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            },
            {
              "id": "B",
              "text": "Option C: Pyloromyotomy does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            },
            {
              "id": "C",
              "text": "Option D: Barium enema as definitive treatment does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge after changing formula does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pyloromyotomy does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after changing formula does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            },
            {
              "id": "C",
              "text": "Option D: Barium enema as definitive treatment does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pyloromyotomy does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Barium enema as definitive treatment does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after changing formula does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            },
            {
              "id": "C",
              "text": "Option C: Pyloromyotomy does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Barium enema as definitive treatment does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe until stool passage does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            },
            {
              "id": "B",
              "text": "Option B: Discharge after changing formula does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            },
            {
              "id": "C",
              "text": "Option C: Pyloromyotomy does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe until stool passage does not adequately address the decisive finding: sudden bilious emesis. Treat a neonate with suspected midgut volvulus as a surgical emergency."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-neonatal-hsv-empiric-acyclovir",
      "expectedHashes": {
        "ranaze_step3_uat": "fbb8666d601b261306baa9f96c10dabc70ce672921767f6a8c1c73fe71acfcc7",
        "ranaze_step3_prd": "fbb8666d601b261306baa9f96c10dabc70ce672921767f6a8c1c73fe71acfcc7"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for polymerase-chain-reaction confirmation does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "B",
              "text": "Option C: Topical acyclovir only does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "C",
              "text": "Option D: Oral valacyclovir does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for polymerase-chain-reaction confirmation does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical acyclovir only does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "B",
              "text": "Option B: Wait for polymerase-chain-reaction confirmation does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "C",
              "text": "Option D: Oral valacyclovir does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical acyclovir only does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral valacyclovir does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "B",
              "text": "Option B: Wait for polymerase-chain-reaction confirmation does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "C",
              "text": "Option C: Topical acyclovir only does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral valacyclovir does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Glucocorticoids without antiviral therapy does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "B",
              "text": "Option B: Wait for polymerase-chain-reaction confirmation does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "C",
              "text": "Option C: Topical acyclovir only does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Glucocorticoids without antiviral therapy does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Phototherapy for the vesicular eruption does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "B",
              "text": "Option B: Wait for polymerase-chain-reaction confirmation does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            },
            {
              "id": "C",
              "text": "Option C: Topical acyclovir only does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Phototherapy for the vesicular eruption does not adequately address the decisive finding: focal seizures. Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-neuroleptic-malignant-syndrome-stop-agent",
      "expectedHashes": {
        "ranaze_step3_uat": "25405a887953a83a7aab42a28a39a6aa328e302f0847a6419ee0d66fde7c5c92",
        "ranaze_step3_prd": "25405a887953a83a7aab42a28a39a6aa328e302f0847a6419ee0d66fde7c5c92"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue haloperidol to treat agitation does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            },
            {
              "id": "B",
              "text": "Option C: Administer an SSRI does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            },
            {
              "id": "C",
              "text": "Option D: Give succinylcholine does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue haloperidol to treat agitation does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer an SSRI does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Continue haloperidol to treat agitation does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            },
            {
              "id": "C",
              "text": "Option D: Give succinylcholine does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer an SSRI does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give succinylcholine does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Continue haloperidol to treat agitation does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            },
            {
              "id": "C",
              "text": "Option C: Administer an SSRI does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give succinylcholine does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with oral hydration does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Continue haloperidol to treat agitation does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            },
            {
              "id": "C",
              "text": "Option C: Administer an SSRI does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with oral hydration does not adequately address the decisive finding: generalized lead-pipe rigidity. Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-open-fracture-early-antibiotics",
      "expectedHashes": {
        "ranaze_step3_uat": "56bc7a0bb118eeb7ba38bc9385e63b511958cc2515c9ced22ab2848fc2c81ca8",
        "ranaze_step3_prd": "56bc7a0bb118eeb7ba38bc9385e63b511958cc2515c9ced22ab2848fc2c81ca8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Close the wound primarily in the emergency department does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "B",
              "text": "Option C: Delay antibiotics until operative cultures return does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "C",
              "text": "Option D: Probe the wound repeatedly to assess depth does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Close the wound primarily in the emergency department does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay antibiotics until operative cultures return does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "B",
              "text": "Option B: Close the wound primarily in the emergency department does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "C",
              "text": "Option D: Probe the wound repeatedly to assess depth does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay antibiotics until operative cultures return does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Probe the wound repeatedly to assess depth does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "B",
              "text": "Option B: Close the wound primarily in the emergency department does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "C",
              "text": "Option C: Delay antibiotics until operative cultures return does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Probe the wound repeatedly to assess depth does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply a circumferential cast over the wound does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "B",
              "text": "Option B: Close the wound primarily in the emergency department does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "C",
              "text": "Option C: Delay antibiotics until operative cultures return does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply a circumferential cast over the wound does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide tetanus prophylaxis as the only infection-prevention measure does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "B",
              "text": "Option B: Close the wound primarily in the emergency department does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            },
            {
              "id": "C",
              "text": "Option C: Delay antibiotics until operative cultures return does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide tetanus prophylaxis as the only infection-prevention measure does not adequately address the decisive finding: bone visible. Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-orbital-cellulitis-iv-antibiotics-imaging",
      "expectedHashes": {
        "ranaze_step3_uat": "6735e1896d8c5d9ff4d1cb9b875be7386b8110a1768c74f4896749e4c9bac938",
        "ranaze_step3_prd": "6735e1896d8c5d9ff4d1cb9b875be7386b8110a1768c74f4896749e4c9bac938"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with topical antibiotic drops at home does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            },
            {
              "id": "B",
              "text": "Option C: Prescribe an oral antihistamine does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            },
            {
              "id": "C",
              "text": "Option D: Patch the eye and reassess in one week does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with topical antibiotic drops at home does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe an oral antihistamine does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            },
            {
              "id": "B",
              "text": "Option B: Treat with topical antibiotic drops at home does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            },
            {
              "id": "C",
              "text": "Option D: Patch the eye and reassess in one week does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe an oral antihistamine does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patch the eye and reassess in one week does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            },
            {
              "id": "B",
              "text": "Option B: Treat with topical antibiotic drops at home does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe an oral antihistamine does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patch the eye and reassess in one week does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform tonometry only does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            },
            {
              "id": "B",
              "text": "Option B: Treat with topical antibiotic drops at home does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            },
            {
              "id": "C",
              "text": "Option C: Prescribe an oral antihistamine does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform tonometry only does not adequately address the decisive finding: pain with eye movement. Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-papillary-muscle-rupture-emergency-surgery",
      "expectedHashes": {
        "ranaze_step3_uat": "89e76d0d5db65e9880d809f00caec7ae5d7890b2e17ecb4d51133ad03b24a62f",
        "ranaze_step3_prd": "89e76d0d5db65e9880d809f00caec7ae5d7890b2e17ecb4d51133ad03b24a62f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Outpatient diuretic adjustment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            },
            {
              "id": "B",
              "text": "Option C: Thrombolysis as sole treatment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            },
            {
              "id": "C",
              "text": "Option D: Observation for spontaneous papillary-muscle healing does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Outpatient diuretic adjustment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thrombolysis as sole treatment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            },
            {
              "id": "B",
              "text": "Option B: Outpatient diuretic adjustment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            },
            {
              "id": "C",
              "text": "Option D: Observation for spontaneous papillary-muscle healing does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thrombolysis as sole treatment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation for spontaneous papillary-muscle healing does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            },
            {
              "id": "B",
              "text": "Option B: Outpatient diuretic adjustment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            },
            {
              "id": "C",
              "text": "Option C: Thrombolysis as sole treatment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation for spontaneous papillary-muscle healing does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Permanent pacemaker placement does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            },
            {
              "id": "B",
              "text": "Option B: Outpatient diuretic adjustment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            },
            {
              "id": "C",
              "text": "Option C: Thrombolysis as sole treatment does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Permanent pacemaker placement does not adequately address the decisive finding: a flail mitral leaflet. Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-pcp-hypoxemia-adjunctive-steroids",
      "expectedHashes": {
        "ranaze_step3_uat": "d6df41c9769250b7ebbed6ad5261e9a21a4fac212e9a6873b968fd1853169082",
        "ranaze_step3_prd": "d6df41c9769250b7ebbed6ad5261e9a21a4fac212e9a6873b968fd1853169082"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inhaled bronchodilator only does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            },
            {
              "id": "B",
              "text": "Option C: Immediate antiretroviral therapy as the sole pneumonia treatment does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            },
            {
              "id": "C",
              "text": "Option D: Loop diuresis does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inhaled bronchodilator only does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate antiretroviral therapy as the sole pneumonia treatment does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            },
            {
              "id": "B",
              "text": "Option B: Inhaled bronchodilator only does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            },
            {
              "id": "C",
              "text": "Option D: Loop diuresis does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate antiretroviral therapy as the sole pneumonia treatment does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Loop diuresis does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            },
            {
              "id": "B",
              "text": "Option B: Inhaled bronchodilator only does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Immediate antiretroviral therapy as the sole pneumonia treatment does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Loop diuresis does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Therapeutic anticoagulation does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            },
            {
              "id": "B",
              "text": "Option B: Inhaled bronchodilator only does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Immediate antiretroviral therapy as the sole pneumonia treatment does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Therapeutic anticoagulation does not adequately address the decisive finding: diffuse bilateral ground-glass opacities. Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-pediatric-dka-cerebral-injury-hyperosmolar",
      "expectedHashes": {
        "ranaze_step3_uat": "c8b754a7f70717726ae7099f73b064ea38a52f66e6b3c6f1be9a02598f8dd81d",
        "ranaze_step3_prd": "c8b754a7f70717726ae7099f73b064ea38a52f66e6b3c6f1be9a02598f8dd81d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase the insulin infusion sharply does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "B",
              "text": "Option C: Administer intravenous bicarbonate routinely does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "C",
              "text": "Option D: Obtain lumbar puncture before treatment does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase the insulin infusion sharply does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous bicarbonate routinely does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "B",
              "text": "Option B: Increase the insulin infusion sharply does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "C",
              "text": "Option D: Obtain lumbar puncture before treatment does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous bicarbonate routinely does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain lumbar puncture before treatment does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "B",
              "text": "Option B: Increase the insulin infusion sharply does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "C",
              "text": "Option C: Administer intravenous bicarbonate routinely does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain lumbar puncture before treatment does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop all intravenous fluids permanently does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "B",
              "text": "Option B: Increase the insulin infusion sharply does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "C",
              "text": "Option C: Administer intravenous bicarbonate routinely does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop all intravenous fluids permanently does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for head CT confirmation before osmotherapy does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "B",
              "text": "Option B: Increase the insulin infusion sharply does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            },
            {
              "id": "C",
              "text": "Option C: Administer intravenous bicarbonate routinely does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for head CT confirmation before osmotherapy does not adequately address the decisive finding: she develops severe headache. Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-pediatric-intussusception-air-enema",
      "expectedHashes": {
        "ranaze_step3_uat": "6a2eb60c619c899af4a4dd014121c092edf805224833d8f615e67fa544408181",
        "ranaze_step3_prd": "6a2eb60c619c899af4a4dd014121c092edf805224833d8f615e67fa544408181"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate laparotomy without attempted reduction does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            },
            {
              "id": "B",
              "text": "Option C: Upper endoscopy does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            },
            {
              "id": "C",
              "text": "Option D: Oral laxatives and discharge does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate laparotomy without attempted reduction does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Upper endoscopy does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            },
            {
              "id": "B",
              "text": "Option B: Immediate laparotomy without attempted reduction does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            },
            {
              "id": "C",
              "text": "Option D: Oral laxatives and discharge does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Upper endoscopy does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral laxatives and discharge does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            },
            {
              "id": "B",
              "text": "Option B: Immediate laparotomy without attempted reduction does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral laxatives and discharge does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation for spontaneous resolution does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            },
            {
              "id": "B",
              "text": "Option B: Immediate laparotomy without attempted reduction does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation for spontaneous resolution does not adequately address the decisive finding: ultrasonography shows a target-shaped ileocolic mass. Use enema reduction first for uncomplicated, stable ileocolic intussusception."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-pediatric-septic-hip-aspiration",
      "expectedHashes": {
        "ranaze_step3_uat": "356065099dafeef7a78b03356b0fdd633aff5a0c90206e6dee6fc38ae86065fa",
        "ranaze_step3_prd": "356065099dafeef7a78b03356b0fdd633aff5a0c90206e6dee6fc38ae86065fa"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with ibuprofen for transient synovitis does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            },
            {
              "id": "B",
              "text": "Option C: Intra-articular glucocorticoid injection does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            },
            {
              "id": "C",
              "text": "Option D: Wait one week for repeat ultrasonography does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with ibuprofen for transient synovitis does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intra-articular glucocorticoid injection does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with ibuprofen for transient synovitis does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            },
            {
              "id": "C",
              "text": "Option D: Wait one week for repeat ultrasonography does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intra-articular glucocorticoid injection does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait one week for repeat ultrasonography does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with ibuprofen for transient synovitis does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            },
            {
              "id": "C",
              "text": "Option C: Intra-articular glucocorticoid injection does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait one week for repeat ultrasonography does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin physical therapy does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with ibuprofen for transient synovitis does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            },
            {
              "id": "C",
              "text": "Option C: Intra-articular glucocorticoid injection does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin physical therapy does not adequately address the decisive finding: refuses to bear weight. Suspected bacterial arthritis of the hip requires urgent aspiration and source control."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-peritonsillar-abscess-drainage",
      "expectedHashes": {
        "ranaze_step3_uat": "842f8aa709bb021b100a757d767429be9708021dd257e1b1dbe97a86d8139d78",
        "ranaze_step3_prd": "842f8aa709bb021b100a757d767429be9708021dd257e1b1dbe97a86d8139d78"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with throat lozenges alone does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            },
            {
              "id": "B",
              "text": "Option C: Begin anticoagulation does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            },
            {
              "id": "C",
              "text": "Option D: Perform immediate thyroidectomy does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with throat lozenges alone does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin anticoagulation does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            },
            {
              "id": "B",
              "text": "Option B: Treat with throat lozenges alone does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            },
            {
              "id": "C",
              "text": "Option D: Perform immediate thyroidectomy does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin anticoagulation does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate thyroidectomy does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            },
            {
              "id": "B",
              "text": "Option B: Treat with throat lozenges alone does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            },
            {
              "id": "C",
              "text": "Option C: Begin anticoagulation does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate thyroidectomy does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for spontaneous rupture without monitoring does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            },
            {
              "id": "B",
              "text": "Option B: Treat with throat lozenges alone does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            },
            {
              "id": "C",
              "text": "Option C: Begin anticoagulation does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for spontaneous rupture without monitoring does not adequately address the decisive finding: the uvula is displaced. Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-posterior-epistaxis-airway-packing",
      "expectedHashes": {
        "ranaze_step3_uat": "6606bc64d15e68677408578a61f54fd90b423504e286ec4629119b9fc22253a6",
        "ranaze_step3_prd": "6606bc64d15e68677408578a61f54fd90b423504e286ec4629119b9fc22253a6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with humidification does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            },
            {
              "id": "B",
              "text": "Option C: Continue pinching the nasal bridge indefinitely does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            },
            {
              "id": "C",
              "text": "Option D: Perform lumbar puncture does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with humidification does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue pinching the nasal bridge indefinitely does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with humidification does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            },
            {
              "id": "C",
              "text": "Option D: Perform lumbar puncture does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue pinching the nasal bridge indefinitely does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform lumbar puncture does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with humidification does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            },
            {
              "id": "C",
              "text": "Option C: Continue pinching the nasal bridge indefinitely does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform lumbar puncture does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start intranasal glucocorticoids does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            },
            {
              "id": "B",
              "text": "Option B: Discharge with humidification does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            },
            {
              "id": "C",
              "text": "Option C: Continue pinching the nasal bridge indefinitely does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start intranasal glucocorticoids does not adequately address the decisive finding: brisk bleeding into the posterior pharynx. Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-preexcited-af-procainamide",
      "expectedHashes": {
        "ranaze_step3_uat": "98eb4b35a1034167d057ffb732543c29c35cefcda774a1055016da5e7a4ca00c",
        "ranaze_step3_prd": "98eb4b35a1034167d057ffb732543c29c35cefcda774a1055016da5e7a4ca00c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous adenosine does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous diltiazem does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "C",
              "text": "Option D: Intravenous digoxin does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous adenosine does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous diltiazem does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous adenosine does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "C",
              "text": "Option D: Intravenous digoxin does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous diltiazem does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous digoxin does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous adenosine does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous diltiazem does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous digoxin does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous metoprolol does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous adenosine does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous diltiazem does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous metoprolol does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous verapamil does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous adenosine does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous diltiazem does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous verapamil does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carotid sinus massage does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous adenosine does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous diltiazem does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carotid sinus massage does not adequately address the decisive finding: an irregular wide-complex tachycardia. Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-prosthetic-joint-acute-da-ir",
      "expectedHashes": {
        "ranaze_step3_uat": "71af7b96f65ad39c9bad71c9dd56ed4edf3bfaf4c57d16437f25d3c4741957b4",
        "ranaze_step3_prd": "71af7b96f65ad39c9bad71c9dd56ed4edf3bfaf4c57d16437f25d3c4741957b4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No surgery because the implant is stable does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            },
            {
              "id": "B",
              "text": "Option C: Immediate amputation does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            },
            {
              "id": "C",
              "text": "Option D: Chronic suppressive antibiotics without source control does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No surgery because the implant is stable does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate amputation does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            },
            {
              "id": "B",
              "text": "Option B: No surgery because the implant is stable does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            },
            {
              "id": "C",
              "text": "Option D: Chronic suppressive antibiotics without source control does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate amputation does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic suppressive antibiotics without source control does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            },
            {
              "id": "B",
              "text": "Option B: No surgery because the implant is stable does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            },
            {
              "id": "C",
              "text": "Option C: Immediate amputation does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic suppressive antibiotics without source control does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay intervention until the prosthesis loosens does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            },
            {
              "id": "B",
              "text": "Option B: No surgery because the implant is stable does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            },
            {
              "id": "C",
              "text": "Option C: Immediate amputation does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay intervention until the prosthesis loosens does not adequately address the decisive finding: symptoms began 2 days ago. Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-prosthetic-valve-endocarditis-surgery",
      "expectedHashes": {
        "ranaze_step3_uat": "1fd615f7533d5dd1ff2a4a273986a8bef89f52587475b6758c26483d4538d533",
        "ranaze_step3_prd": "1fd615f7533d5dd1ff2a4a273986a8bef89f52587475b6758c26483d4538d533"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Complete antibiotics before considering surgery does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "B",
              "text": "Option C: Stop antibiotics and repeat cultures next month does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "C",
              "text": "Option D: Begin thrombolysis does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Complete antibiotics before considering surgery does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop antibiotics and repeat cultures next month does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "B",
              "text": "Option B: Complete antibiotics before considering surgery does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "C",
              "text": "Option D: Begin thrombolysis does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop antibiotics and repeat cultures next month does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin thrombolysis does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "B",
              "text": "Option B: Complete antibiotics before considering surgery does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "C",
              "text": "Option C: Stop antibiotics and repeat cultures next month does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin thrombolysis does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with anticoagulation alone does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "B",
              "text": "Option B: Complete antibiotics before considering surgery does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "C",
              "text": "Option C: Stop antibiotics and repeat cultures next month does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with anticoagulation alone does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remove the prosthesis percutaneously without surgical planning does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "B",
              "text": "Option B: Complete antibiotics before considering surgery does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            },
            {
              "id": "C",
              "text": "Option C: Stop antibiotics and repeat cultures next month does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remove the prosthesis percutaneously without surgical planning does not adequately address the decisive finding: persistent Staphylococcus aureus bacteremia. Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-pyloric-stenosis-correct-electrolytes",
      "expectedHashes": {
        "ranaze_step3_uat": "40185690dfb83b3da6ccbc623183757a09bc8f37422ab260e64f840ee786cc0e",
        "ranaze_step3_prd": "40185690dfb83b3da6ccbc623183757a09bc8f37422ab260e64f840ee786cc0e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate pyloromyotomy before resuscitation does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            },
            {
              "id": "B",
              "text": "Option C: Emergency bowel resection does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            },
            {
              "id": "C",
              "text": "Option D: Oral feeding challenge does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate pyloromyotomy before resuscitation does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Emergency bowel resection does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Immediate pyloromyotomy before resuscitation does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            },
            {
              "id": "C",
              "text": "Option D: Oral feeding challenge does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Emergency bowel resection does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral feeding challenge does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Immediate pyloromyotomy before resuscitation does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            },
            {
              "id": "C",
              "text": "Option C: Emergency bowel resection does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral feeding challenge does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acid suppression alone does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Immediate pyloromyotomy before resuscitation does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            },
            {
              "id": "C",
              "text": "Option C: Emergency bowel resection does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acid suppression alone does not adequately address the decisive finding: projectile nonbilious vomiting. Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-quality-improvement-pdsa",
      "expectedHashes": {
        "ranaze_step3_uat": "b418450a4859155e549c1a8057c16447894fc4cd81237f40aa23d33b88a6b9f6",
        "ranaze_step3_prd": "b418450a4859155e549c1a8057c16447894fc4cd81237f40aa23d33b88a6b9f6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Case-control study does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            },
            {
              "id": "B",
              "text": "Option C: Root cause analysis after a sentinel event does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            },
            {
              "id": "C",
              "text": "Option D: Randomized phase 3 drug trial does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Case-control study does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Root cause analysis after a sentinel event does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            },
            {
              "id": "B",
              "text": "Option B: Case-control study does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            },
            {
              "id": "C",
              "text": "Option D: Randomized phase 3 drug trial does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Root cause analysis after a sentinel event does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Randomized phase 3 drug trial does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            },
            {
              "id": "B",
              "text": "Option B: Case-control study does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            },
            {
              "id": "C",
              "text": "Option C: Root cause analysis after a sentinel event does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Randomized phase 3 drug trial does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Failure concealment does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            },
            {
              "id": "B",
              "text": "Option B: Case-control study does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            },
            {
              "id": "C",
              "text": "Option C: Root cause analysis after a sentinel event does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Failure concealment does not adequately address the decisive finding: tests the reminder for one physician. Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-retinal-detachment-urgent-repair",
      "expectedHashes": {
        "ranaze_step3_uat": "c7e7460d819c51d6e3a0d2ed37683e31c7676ba5de284db509d8541548bcebfe",
        "ranaze_step3_prd": "c7e7460d819c51d6e3a0d2ed37683e31c7676ba5de284db509d8541548bcebfe"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine optometry appointment in six months does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            },
            {
              "id": "B",
              "text": "Option C: Topical antibiotics does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            },
            {
              "id": "C",
              "text": "Option D: Carotid endarterectomy does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine optometry appointment in six months does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical antibiotics does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            },
            {
              "id": "B",
              "text": "Option B: Routine optometry appointment in six months does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            },
            {
              "id": "C",
              "text": "Option D: Carotid endarterectomy does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical antibiotics does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carotid endarterectomy does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            },
            {
              "id": "B",
              "text": "Option B: Routine optometry appointment in six months does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            },
            {
              "id": "C",
              "text": "Option C: Topical antibiotics does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carotid endarterectomy does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassurance for ocular migraine does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            },
            {
              "id": "B",
              "text": "Option B: Routine optometry appointment in six months does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            },
            {
              "id": "C",
              "text": "Option C: Topical antibiotics does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassurance for ocular migraine does not adequately address the decisive finding: a curtain descending across the right visual field. Urgently repair a macula-on or macula-threatening retinal detachment."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-rhabdomyolysis-volume-resuscitation",
      "expectedHashes": {
        "ranaze_step3_uat": "eae169708b598e3184cdc2ec09befe769be03f063642264173dfda15053f0057",
        "ranaze_step3_prd": "eae169708b598e3184cdc2ec09befe769be03f063642264173dfda15053f0057"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine bicarbonate and mannitol for every patient does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "B",
              "text": "Option C: Fluid restriction does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "C",
              "text": "Option D: Immediate dialysis despite preserved urine output does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine bicarbonate and mannitol for every patient does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fluid restriction does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "B",
              "text": "Option B: Routine bicarbonate and mannitol for every patient does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "C",
              "text": "Option D: Immediate dialysis despite preserved urine output does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fluid restriction does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate dialysis despite preserved urine output does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "B",
              "text": "Option B: Routine bicarbonate and mannitol for every patient does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "C",
              "text": "Option C: Fluid restriction does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate dialysis despite preserved urine output does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose loop diuretics as sole therapy does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "B",
              "text": "Option B: Routine bicarbonate and mannitol for every patient does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "C",
              "text": "Option C: Fluid restriction does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose loop diuretics as sole therapy does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay fluids until urine myoglobin is quantified does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "B",
              "text": "Option B: Routine bicarbonate and mannitol for every patient does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            },
            {
              "id": "C",
              "text": "Option C: Fluid restriction does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay fluids until urine myoglobin is quantified does not adequately address the decisive finding: urine is dark. Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-septic-shock-antibiotics-source-control",
      "expectedHashes": {
        "ranaze_step3_uat": "fee819469fc37caa281c9561a54c2c64ef436c356cd312b06d29e043044c57c2",
        "ranaze_step3_prd": "fee819469fc37caa281c9561a54c2c64ef436c356cd312b06d29e043044c57c2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay antibiotics until culture speciation does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "B",
              "text": "Option C: Continue unlimited crystalloid without vasopressor does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "C",
              "text": "Option D: Treat with glucocorticoids alone does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay antibiotics until culture speciation does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue unlimited crystalloid without vasopressor does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "B",
              "text": "Option B: Delay antibiotics until culture speciation does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "C",
              "text": "Option D: Treat with glucocorticoids alone does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue unlimited crystalloid without vasopressor does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with glucocorticoids alone does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "B",
              "text": "Option B: Delay antibiotics until culture speciation does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "C",
              "text": "Option C: Continue unlimited crystalloid without vasopressor does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with glucocorticoids alone does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule outpatient stone removal does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "B",
              "text": "Option B: Delay antibiotics until culture speciation does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "C",
              "text": "Option C: Continue unlimited crystalloid without vasopressor does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule outpatient stone removal does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start vasopressin monotherapy without drainage does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "B",
              "text": "Option B: Delay antibiotics until culture speciation does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "C",
              "text": "Option C: Continue unlimited crystalloid without vasopressor does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start vasopressin monotherapy without drainage does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give diuretics to increase urine flow through the obstruction does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "B",
              "text": "Option B: Delay antibiotics until culture speciation does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            },
            {
              "id": "C",
              "text": "Option C: Continue unlimited crystalloid without vasopressor does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give diuretics to increase urine flow through the obstruction does not adequately address the decisive finding: remains hypotensive after initial crystalloid resuscitation. Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-severe-malaria-iv-artesunate",
      "expectedHashes": {
        "ranaze_step3_uat": "108919f311fe00dceec5cc0f7bf9dd54f57434d98e46c7f958ed05e9b453a7c1",
        "ranaze_step3_prd": "108919f311fe00dceec5cc0f7bf9dd54f57434d98e46c7f958ed05e9b453a7c1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral chloroquine does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            },
            {
              "id": "B",
              "text": "Option C: Doxycycline monotherapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            },
            {
              "id": "C",
              "text": "Option D: Exchange transfusion without antimalarial therapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral chloroquine does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Doxycycline monotherapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            },
            {
              "id": "B",
              "text": "Option B: Oral chloroquine does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            },
            {
              "id": "C",
              "text": "Option D: Exchange transfusion without antimalarial therapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Doxycycline monotherapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exchange transfusion without antimalarial therapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            },
            {
              "id": "B",
              "text": "Option B: Oral chloroquine does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            },
            {
              "id": "C",
              "text": "Option C: Doxycycline monotherapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exchange transfusion without antimalarial therapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for species confirmation at a reference laboratory does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            },
            {
              "id": "B",
              "text": "Option B: Oral chloroquine does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            },
            {
              "id": "C",
              "text": "Option C: Doxycycline monotherapy does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for species confirmation at a reference laboratory does not adequately address the decisive finding: confusion. Treat severe malaria immediately with intravenous artesunate."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-sickle-acute-chest-exchange-transfusion",
      "expectedHashes": {
        "ranaze_step3_uat": "7e835d5e6ff87e5c2200d351a70f7e69c293a987cdfb19a8ea5873120a663103",
        "ranaze_step3_prd": "7e835d5e6ff87e5c2200d351a70f7e69c293a987cdfb19a8ea5873120a663103"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat simple transfusions without limit does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            },
            {
              "id": "B",
              "text": "Option C: Discontinue antibiotics does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            },
            {
              "id": "C",
              "text": "Option D: Therapeutic phlebotomy alone does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat simple transfusions without limit does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discontinue antibiotics does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Repeat simple transfusions without limit does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            },
            {
              "id": "C",
              "text": "Option D: Therapeutic phlebotomy alone does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discontinue antibiotics does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Therapeutic phlebotomy alone does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Repeat simple transfusions without limit does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            },
            {
              "id": "C",
              "text": "Option C: Discontinue antibiotics does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Therapeutic phlebotomy alone does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay escalation until mechanical ventilation is required does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Repeat simple transfusions without limit does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            },
            {
              "id": "C",
              "text": "Option C: Discontinue antibiotics does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay escalation until mechanical ventilation is required does not adequately address the decisive finding: hypoxemia worsens. Use exchange transfusion for severe or rapidly progressive acute chest syndrome."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-strangulated-small-bowel-obstruction-surgery",
      "expectedHashes": {
        "ranaze_step3_uat": "e25d2e5edeaadbc8e0c03f76693af30110937a8e5b0254851b617df4b41b1ff5",
        "ranaze_step3_prd": "e25d2e5edeaadbc8e0c03f76693af30110937a8e5b0254851b617df4b41b1ff5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue nonoperative observation for 72 hours does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            },
            {
              "id": "B",
              "text": "Option C: Administer an oral laxative does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            },
            {
              "id": "C",
              "text": "Option D: Perform colonoscopy does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue nonoperative observation for 72 hours does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer an oral laxative does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            },
            {
              "id": "B",
              "text": "Option B: Continue nonoperative observation for 72 hours does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            },
            {
              "id": "C",
              "text": "Option D: Perform colonoscopy does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer an oral laxative does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform colonoscopy does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            },
            {
              "id": "B",
              "text": "Option B: Continue nonoperative observation for 72 hours does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Administer an oral laxative does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform colonoscopy does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge after antiemetic therapy does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            },
            {
              "id": "B",
              "text": "Option B: Continue nonoperative observation for 72 hours does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Administer an oral laxative does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge after antiemetic therapy does not adequately address the decisive finding: a closed-loop small-bowel obstruction. Operate urgently when small-bowel obstruction has signs of strangulation or ischemia."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-symptomatic-severe-aortic-stenosis-replacement",
      "expectedHashes": {
        "ranaze_step3_uat": "b6b85bed64221ea8cc79929e8472ce8b7d439bde7b9c46d449d087775e43cbee",
        "ranaze_step3_prd": "b6b85bed64221ea8cc79929e8472ce8b7d439bde7b9c46d449d087775e43cbee"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exercise training alone does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            },
            {
              "id": "B",
              "text": "Option C: Long-term nitrate escalation does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            },
            {
              "id": "C",
              "text": "Option D: Balloon valvuloplasty as definitive routine therapy does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exercise training alone does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long-term nitrate escalation does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Exercise training alone does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            },
            {
              "id": "C",
              "text": "Option D: Balloon valvuloplasty as definitive routine therapy does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long-term nitrate escalation does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Balloon valvuloplasty as definitive routine therapy does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Exercise training alone does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            },
            {
              "id": "C",
              "text": "Option C: Long-term nitrate escalation does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Balloon valvuloplasty as definitive routine therapy does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation until ventricular function declines does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Exercise training alone does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            },
            {
              "id": "C",
              "text": "Option C: Long-term nitrate escalation does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation until ventricular function declines does not adequately address the decisive finding: exertional syncope. Valve replacement is indicated for symptomatic severe aortic stenosis."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-toxic-megacolon-surgical-escalation",
      "expectedHashes": {
        "ranaze_step3_uat": "8d07403b9a6bdae61fb9869e4c2f9c391d806889d190bd7721408554a8a41c35",
        "ranaze_step3_prd": "8d07403b9a6bdae61fb9869e4c2f9c391d806889d190bd7721408554a8a41c35"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Colonoscopy with full bowel preparation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "B",
              "text": "Option C: Escalate opioid analgesics does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "C",
              "text": "Option D: Discharge on oral mesalamine does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Colonoscopy with full bowel preparation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Escalate opioid analgesics does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy with full bowel preparation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "C",
              "text": "Option D: Discharge on oral mesalamine does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Escalate opioid analgesics does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge on oral mesalamine does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy with full bowel preparation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "C",
              "text": "Option C: Escalate opioid analgesics does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge on oral mesalamine does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue medical therapy indefinitely does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy with full bowel preparation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "C",
              "text": "Option C: Escalate opioid analgesics does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue medical therapy indefinitely does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer an antimotility agent does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy with full bowel preparation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "C",
              "text": "Option C: Escalate opioid analgesics does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer an antimotility agent does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Attempt endoscopic balloon dilation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy with full bowel preparation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            },
            {
              "id": "C",
              "text": "Option C: Escalate opioid analgesics does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Attempt endoscopic balloon dilation does not adequately address the decisive finding: abdominal distention worsens. Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-tumor-lysis-rasburicase",
      "expectedHashes": {
        "ranaze_step3_uat": "8967da90b96d1bd0c281a8a537c23a5b21bafcb5dda1a794f2faba33d6ac4690",
        "ranaze_step3_prd": "8967da90b96d1bd0c281a8a537c23a5b21bafcb5dda1a794f2faba33d6ac4690"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Allopurinol as the only treatment for existing severe hyperuricemia does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "B",
              "text": "Option C: Calcium routinely despite no tetany does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "C",
              "text": "Option D: Hydrochlorothiazide does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Allopurinol as the only treatment for existing severe hyperuricemia does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Calcium routinely despite no tetany does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "B",
              "text": "Option B: Allopurinol as the only treatment for existing severe hyperuricemia does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "C",
              "text": "Option D: Hydrochlorothiazide does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Calcium routinely despite no tetany does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hydrochlorothiazide does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "B",
              "text": "Option B: Allopurinol as the only treatment for existing severe hyperuricemia does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "C",
              "text": "Option C: Calcium routinely despite no tetany does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hydrochlorothiazide does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral iron does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "B",
              "text": "Option B: Allopurinol as the only treatment for existing severe hyperuricemia does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "C",
              "text": "Option C: Calcium routinely despite no tetany does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral iron does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Probenecid despite acute kidney injury does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "B",
              "text": "Option B: Allopurinol as the only treatment for existing severe hyperuricemia does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            },
            {
              "id": "C",
              "text": "Option C: Calcium routinely despite no tetany does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Probenecid despite acute kidney injury does not adequately address the decisive finding: marked hyperuricemia. Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-wernicke-thiamine-before-glucose",
      "expectedHashes": {
        "ranaze_step3_uat": "5eaf0811b30aed9d910e7c24090b038cb8007d31d636e475bd43113ddffade77",
        "ranaze_step3_prd": "5eaf0811b30aed9d910e7c24090b038cb8007d31d636e475bd43113ddffade77"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral folate alone does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            },
            {
              "id": "B",
              "text": "Option C: Haloperidol as sole treatment does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            },
            {
              "id": "C",
              "text": "Option D: Wait for thiamine-level confirmation does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral folate alone does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Haloperidol as sole treatment does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            },
            {
              "id": "B",
              "text": "Option B: Oral folate alone does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            },
            {
              "id": "C",
              "text": "Option D: Wait for thiamine-level confirmation does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Haloperidol as sole treatment does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for thiamine-level confirmation does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            },
            {
              "id": "B",
              "text": "Option B: Oral folate alone does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            },
            {
              "id": "C",
              "text": "Option C: Haloperidol as sole treatment does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for thiamine-level confirmation does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dextrose alone does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            },
            {
              "id": "B",
              "text": "Option B: Oral folate alone does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            },
            {
              "id": "C",
              "text": "Option C: Haloperidol as sole treatment does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dextrose alone does not adequately address the decisive finding: gaze-evoked nystagmus. Treat suspected Wernicke encephalopathy immediately with parenteral thiamine."
        }
      }
    },
    {
      "externalId": "gap-d4-20260730-wrong-site-surgery-timeout",
      "expectedHashes": {
        "ranaze_step3_uat": "004e7846f77468fef02825cd3dc4c22a1ffc6acf444632cafc52c7383c5e3916",
        "ranaze_step3_prd": "004e7846f77468fef02825cd3dc4c22a1ffc6acf444632cafc52c7383c5e3916"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed using the electronic schedule does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "B",
              "text": "Option C: Let the most senior clinician choose a side does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "C",
              "text": "Option D: Operate on both knees does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed using the electronic schedule does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Let the most senior clinician choose a side does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "B",
              "text": "Option B: Proceed using the electronic schedule does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "C",
              "text": "Option D: Operate on both knees does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Let the most senior clinician choose a side does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Operate on both knees does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "B",
              "text": "Option B: Proceed using the electronic schedule does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "C",
              "text": "Option C: Let the most senior clinician choose a side does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Operate on both knees does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Document the discrepancy after surgery does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "B",
              "text": "Option B: Proceed using the electronic schedule does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "C",
              "text": "Option C: Let the most senior clinician choose a side does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Document the discrepancy after surgery does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask anesthesia to choose based on room setup does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "B",
              "text": "Option B: Proceed using the electronic schedule does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "C",
              "text": "Option C: Let the most senior clinician choose a side does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask anesthesia to choose based on room setup does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cover the conflicting radiograph and proceed does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "B",
              "text": "Option B: Proceed using the electronic schedule does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            },
            {
              "id": "C",
              "text": "Option C: Let the most senior clinician choose a side does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cover the conflicting radiograph and proceed does not adequately address the decisive finding: the consent says left knee. Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-aaa-screening",
      "expectedHashes": {
        "ranaze_step3_uat": "9657b48eb4fcb4c2c856a64ea225c975a2382843366e3fc80dc28b26b149b7b2",
        "ranaze_step3_prd": "9657b48eb4fcb4c2c856a64ea225c975a2382843366e3fc80dc28b26b149b7b2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Annual abdominal CT does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            },
            {
              "id": "B",
              "text": "Option C: No screening because he quit smoking does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            },
            {
              "id": "C",
              "text": "Option D: Carotid ultrasonography does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Annual abdominal CT does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No screening because he quit smoking does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            },
            {
              "id": "B",
              "text": "Option B: Annual abdominal CT does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            },
            {
              "id": "C",
              "text": "Option D: Carotid ultrasonography does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No screening because he quit smoking does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carotid ultrasonography does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            },
            {
              "id": "B",
              "text": "Option B: Annual abdominal CT does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            },
            {
              "id": "C",
              "text": "Option C: No screening because he quit smoking does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carotid ultrasonography does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serial abdominal radiographs does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            },
            {
              "id": "B",
              "text": "Option B: Annual abdominal CT does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            },
            {
              "id": "C",
              "text": "Option C: No screening because he quit smoking does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serial abdominal radiographs does not fit the decisive finding: 68-year-old man. Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-ace-inhibitor-angioedema-airway",
      "expectedHashes": {
        "ranaze_step3_uat": "a73c231a7bf65b34fa27c85ab3974d592c85507e8768b55677aa75000527541d",
        "ranaze_step3_prd": "a73c231a7bf65b34fa27c85ab3974d592c85507e8768b55677aa75000527541d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for oxygen desaturation does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            },
            {
              "id": "B",
              "text": "Option C: Give an oral antihistamine and discharge does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            },
            {
              "id": "C",
              "text": "Option D: Continue lisinopril after swelling resolves does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for oxygen desaturation does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give an oral antihistamine and discharge does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            },
            {
              "id": "B",
              "text": "Option B: Wait for oxygen desaturation does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            },
            {
              "id": "C",
              "text": "Option D: Continue lisinopril after swelling resolves does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give an oral antihistamine and discharge does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue lisinopril after swelling resolves does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            },
            {
              "id": "B",
              "text": "Option B: Wait for oxygen desaturation does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            },
            {
              "id": "C",
              "text": "Option C: Give an oral antihistamine and discharge does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue lisinopril after swelling resolves does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform skin-prick testing before treatment does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            },
            {
              "id": "B",
              "text": "Option B: Wait for oxygen desaturation does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            },
            {
              "id": "C",
              "text": "Option C: Give an oral antihistamine and discharge does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform skin-prick testing before treatment does not fit the decisive finding: cannot handle secretions. In ACE inhibitor angioedema, airway findings\u2014not oxygen saturation alone\u2014determine the need for early airway control."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-adrenal-crisis",
      "expectedHashes": {
        "ranaze_step3_uat": "f177c01338595085b95e4a1ed41e5bbd9f418c3f5c312083d117be8142968d3c",
        "ranaze_step3_prd": "f177c01338595085b95e4a1ed41e5bbd9f418c3f5c312083d117be8142968d3c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for cosyntropin testing does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            },
            {
              "id": "B",
              "text": "Option C: Fluid restriction does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            },
            {
              "id": "C",
              "text": "Option D: Insulin without glucose does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for cosyntropin testing does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fluid restriction does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for cosyntropin testing does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            },
            {
              "id": "C",
              "text": "Option D: Insulin without glucose does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fluid restriction does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Insulin without glucose does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for cosyntropin testing does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            },
            {
              "id": "C",
              "text": "Option C: Fluid restriction does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Insulin without glucose does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral fludrocortisone alone does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for cosyntropin testing does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            },
            {
              "id": "C",
              "text": "Option C: Fluid restriction does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral fludrocortisone alone does not fit the decisive finding: blood pressure of 72/40 mm Hg. Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-alcohol-withdrawal-delirium-benzodiazepines",
      "expectedHashes": {
        "ranaze_step3_uat": "8617831b4945f6879e4b542c44ea927313b6f9b40fe666b93907374f38e9024a",
        "ranaze_step3_prd": "8617831b4945f6879e4b542c44ea927313b6f9b40fe666b93907374f38e9024a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Haloperidol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            },
            {
              "id": "B",
              "text": "Option C: Propranolol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            },
            {
              "id": "C",
              "text": "Option D: Disulfiram immediately does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Haloperidol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Propranolol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            },
            {
              "id": "B",
              "text": "Option B: Haloperidol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            },
            {
              "id": "C",
              "text": "Option D: Disulfiram immediately does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Propranolol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Disulfiram immediately does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            },
            {
              "id": "B",
              "text": "Option B: Haloperidol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            },
            {
              "id": "C",
              "text": "Option C: Propranolol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Disulfiram immediately does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Physical restraints without medication does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            },
            {
              "id": "B",
              "text": "Option B: Haloperidol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            },
            {
              "id": "C",
              "text": "Option C: Propranolol alone does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Physical restraints without medication does not fit the decisive finding: 72 hours after his last drink. Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-anaphylaxis-epinephrine",
      "expectedHashes": {
        "ranaze_step3_uat": "789593b247990dbb786f2b83a1502dad50960ec9c5f91f8c94a22e88f28044e6",
        "ranaze_step3_prd": "789593b247990dbb786f2b83a1502dad50960ec9c5f91f8c94a22e88f28044e6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous diphenhydramine does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            },
            {
              "id": "B",
              "text": "Option C: Nebulized albuterol alone does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            },
            {
              "id": "C",
              "text": "Option D: Intravenous glucocorticoid does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous diphenhydramine does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nebulized albuterol alone does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous diphenhydramine does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            },
            {
              "id": "C",
              "text": "Option D: Intravenous glucocorticoid does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nebulized albuterol alone does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous glucocorticoid does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous diphenhydramine does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            },
            {
              "id": "C",
              "text": "Option C: Nebulized albuterol alone does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous glucocorticoid does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcutaneous epinephrine after IV access does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous diphenhydramine does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            },
            {
              "id": "C",
              "text": "Option C: Nebulized albuterol alone does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcutaneous epinephrine after IV access does not fit the decisive finding: blood pressure of 78/42 mm Hg. Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-anorexia-bradycardia-inpatient",
      "expectedHashes": {
        "ranaze_step3_uat": "910d0800d9c805e772a59467073de204034a479e4fc4f3492c37fffc7c9ff7e5",
        "ranaze_step3_prd": "910d0800d9c805e772a59467073de204034a479e4fc4f3492c37fffc7c9ff7e5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Weekly outpatient weighing only does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            },
            {
              "id": "B",
              "text": "Option C: Begin a stimulant for fatigue does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe exercise to restore bone mass does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Weekly outpatient weighing only does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin a stimulant for fatigue does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            },
            {
              "id": "B",
              "text": "Option B: Weekly outpatient weighing only does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe exercise to restore bone mass does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin a stimulant for fatigue does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe exercise to restore bone mass does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            },
            {
              "id": "B",
              "text": "Option B: Weekly outpatient weighing only does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            },
            {
              "id": "C",
              "text": "Option C: Begin a stimulant for fatigue does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe exercise to restore bone mass does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay care until amenorrhea lasts one year does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            },
            {
              "id": "B",
              "text": "Option B: Weekly outpatient weighing only does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            },
            {
              "id": "C",
              "text": "Option C: Begin a stimulant for fatigue does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay care until amenorrhea lasts one year does not fit the decisive finding: pulse is 42/min. Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-capacity-treatment-refusal",
      "expectedHashes": {
        "ranaze_step3_uat": "d7918a956db775244929dd02fd8ae621d87dc2663076efcb4985d736ddb73ea0",
        "ranaze_step3_prd": "d7918a956db775244929dd02fd8ae621d87dc2663076efcb4985d736ddb73ea0"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain family consent and operate does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "B",
              "text": "Option C: Assume schizophrenia eliminates capacity does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "C",
              "text": "Option D: Seek an emergency court order solely because death is possible does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain family consent and operate does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Assume schizophrenia eliminates capacity does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "B",
              "text": "Option B: Obtain family consent and operate does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "C",
              "text": "Option D: Seek an emergency court order solely because death is possible does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Assume schizophrenia eliminates capacity does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Seek an emergency court order solely because death is possible does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "B",
              "text": "Option B: Obtain family consent and operate does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "C",
              "text": "Option C: Assume schizophrenia eliminates capacity does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Seek an emergency court order solely because death is possible does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sedate him and perform surgery does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "B",
              "text": "Option B: Obtain family consent and operate does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            },
            {
              "id": "C",
              "text": "Option C: Assume schizophrenia eliminates capacity does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sedate him and perform surgery does not fit the decisive finding: accurately explains that without surgery he may die. Respect a capacitated patient\u0027s informed refusal even when clinicians or family strongly disagree."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-catatonia-lorazepam-challenge",
      "expectedHashes": {
        "ranaze_step3_uat": "20ec0d6ec872e9c6ed7670b5088ca73a29b1c090f43767caf79a20f553a672fd",
        "ranaze_step3_prd": "20ec0d6ec872e9c6ed7670b5088ca73a29b1c090f43767caf79a20f553a672fd"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin high-potency antipsychotic monotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            },
            {
              "id": "B",
              "text": "Option C: Use physical restraints as definitive treatment does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            },
            {
              "id": "C",
              "text": "Option D: Discharge for outpatient psychotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin high-potency antipsychotic monotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use physical restraints as definitive treatment does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            },
            {
              "id": "B",
              "text": "Option B: Begin high-potency antipsychotic monotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            },
            {
              "id": "C",
              "text": "Option D: Discharge for outpatient psychotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use physical restraints as definitive treatment does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge for outpatient psychotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            },
            {
              "id": "B",
              "text": "Option B: Begin high-potency antipsychotic monotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            },
            {
              "id": "C",
              "text": "Option C: Use physical restraints as definitive treatment does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge for outpatient psychotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for fever before treating does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            },
            {
              "id": "B",
              "text": "Option B: Begin high-potency antipsychotic monotherapy does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            },
            {
              "id": "C",
              "text": "Option C: Use physical restraints as definitive treatment does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for fever before treating does not fit the decisive finding: maintains imposed postures. Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-central-line-bundle",
      "expectedHashes": {
        "ranaze_step3_uat": "a9cf80ad1afe8302919c07ca655bec3ddc3dd1656b64aa4121d5d22904b00a60",
        "ranaze_step3_prd": "a9cf80ad1afe8302919c07ca655bec3ddc3dd1656b64aa4121d5d22904b00a60"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat every patient with prophylactic antibiotics does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            },
            {
              "id": "B",
              "text": "Option C: Replace every line daily does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            },
            {
              "id": "C",
              "text": "Option D: Publish clinician names without process changes does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat every patient with prophylactic antibiotics does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Replace every line daily does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            },
            {
              "id": "B",
              "text": "Option B: Treat every patient with prophylactic antibiotics does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            },
            {
              "id": "C",
              "text": "Option D: Publish clinician names without process changes does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Replace every line daily does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Publish clinician names without process changes does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            },
            {
              "id": "B",
              "text": "Option B: Treat every patient with prophylactic antibiotics does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            },
            {
              "id": "C",
              "text": "Option C: Replace every line daily does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Publish clinician names without process changes does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Culture all line tips weekly does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            },
            {
              "id": "B",
              "text": "Option B: Treat every patient with prophylactic antibiotics does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            },
            {
              "id": "C",
              "text": "Option C: Replace every line daily does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Culture all line tips weekly does not fit the decisive finding: no daily review of line necessity. Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-cervical-screening-immunized",
      "expectedHashes": {
        "ranaze_step3_uat": "0f266aa8f625ad4a37325667161a43729d1d4bb1862fcd8f2542f9ba7a172c73",
        "ranaze_step3_prd": "0f266aa8f625ad4a37325667161a43729d1d4bb1862fcd8f2542f9ba7a172c73"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop screening because vaccination eliminates risk does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            },
            {
              "id": "B",
              "text": "Option C: Perform annual endometrial biopsy does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            },
            {
              "id": "C",
              "text": "Option D: Screen only if symptoms develop does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop screening because vaccination eliminates risk does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform annual endometrial biopsy does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            },
            {
              "id": "B",
              "text": "Option B: Stop screening because vaccination eliminates risk does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            },
            {
              "id": "C",
              "text": "Option D: Screen only if symptoms develop does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform annual endometrial biopsy does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Screen only if symptoms develop does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            },
            {
              "id": "B",
              "text": "Option B: Stop screening because vaccination eliminates risk does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            },
            {
              "id": "C",
              "text": "Option C: Perform annual endometrial biopsy does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Screen only if symptoms develop does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin ovarian cancer screening instead does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            },
            {
              "id": "B",
              "text": "Option B: Stop screening because vaccination eliminates risk does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            },
            {
              "id": "C",
              "text": "Option C: Perform annual endometrial biopsy does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin ovarian cancer screening instead does not fit the decisive finding: complete HPV vaccine series. HPV-vaccinated patients still need routine age-appropriate cervical cancer screening."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-colorectal-screening-positive-fit",
      "expectedHashes": {
        "ranaze_step3_uat": "9a0eb4e6f660d47be47882a1142b3b65fd8e33c181715e86f3d600535867af10",
        "ranaze_step3_prd": "9a0eb4e6f660d47be47882a1142b3b65fd8e33c181715e86f3d600535867af10"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat the fecal test immediately does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            },
            {
              "id": "B",
              "text": "Option C: CT abdomen without bowel preparation does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            },
            {
              "id": "C",
              "text": "Option D: Reassure because hemoglobin is normal does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat the fecal test immediately does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT abdomen without bowel preparation does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            },
            {
              "id": "B",
              "text": "Option B: Repeat the fecal test immediately does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            },
            {
              "id": "C",
              "text": "Option D: Reassure because hemoglobin is normal does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT abdomen without bowel preparation does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassure because hemoglobin is normal does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            },
            {
              "id": "B",
              "text": "Option B: Repeat the fecal test immediately does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            },
            {
              "id": "C",
              "text": "Option C: CT abdomen without bowel preparation does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassure because hemoglobin is normal does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin aspirin and repeat testing next year does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            },
            {
              "id": "B",
              "text": "Option B: Repeat the fecal test immediately does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            },
            {
              "id": "C",
              "text": "Option C: CT abdomen without bowel preparation does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin aspirin and repeat testing next year does not fit the decisive finding: fecal immunochemical test, which is positive. Follow every positive stool-based colorectal cancer screen with timely colonoscopy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-common-variable-immunodeficiency",
      "expectedHashes": {
        "ranaze_step3_uat": "961240edcb666ccd984feff0fcb846becce962402950c2f5d8f20448120088a0",
        "ranaze_step3_prd": "961240edcb666ccd984feff0fcb846becce962402950c2f5d8f20448120088a0"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Daily systemic glucocorticoids does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            },
            {
              "id": "B",
              "text": "Option C: Splenectomy does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            },
            {
              "id": "C",
              "text": "Option D: Live vaccines monthly does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Daily systemic glucocorticoids does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Splenectomy does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            },
            {
              "id": "B",
              "text": "Option B: Daily systemic glucocorticoids does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            },
            {
              "id": "C",
              "text": "Option D: Live vaccines monthly does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Splenectomy does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Live vaccines monthly does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            },
            {
              "id": "B",
              "text": "Option B: Daily systemic glucocorticoids does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            },
            {
              "id": "C",
              "text": "Option C: Splenectomy does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Live vaccines monthly does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No treatment because B cells are present does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            },
            {
              "id": "B",
              "text": "Option B: Daily systemic glucocorticoids does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            },
            {
              "id": "C",
              "text": "Option C: Splenectomy does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No treatment because B cells are present does not fit the decisive finding: vaccine antibody responses are poor. Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-confidentiality-driving-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "50f39018bcc7fd0d4c949d196ad4530e339b883e77be389230e3c48e72544010",
        "ranaze_step3_prd": "50f39018bcc7fd0d4c949d196ad4530e339b883e77be389230e3c48e72544010"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maintain absolute confidentiality does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            },
            {
              "id": "B",
              "text": "Option C: Notify the driver\u0027s employer and all passengers does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            },
            {
              "id": "C",
              "text": "Option D: Post a warning publicly does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maintain absolute confidentiality does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Notify the driver\u0027s employer and all passengers does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            },
            {
              "id": "B",
              "text": "Option B: Maintain absolute confidentiality does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            },
            {
              "id": "C",
              "text": "Option D: Post a warning publicly does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Notify the driver\u0027s employer and all passengers does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Post a warning publicly does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            },
            {
              "id": "B",
              "text": "Option B: Maintain absolute confidentiality does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            },
            {
              "id": "C",
              "text": "Option C: Notify the driver\u0027s employer and all passengers does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Post a warning publicly does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe a placebo and take no other action does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            },
            {
              "id": "B",
              "text": "Option B: Maintain absolute confidentiality does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            },
            {
              "id": "C",
              "text": "Option C: Notify the driver\u0027s employer and all passengers does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe a placebo and take no other action does not fit the decisive finding: state law mandates clinician reporting. When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-control-chart-special-cause",
      "expectedHashes": {
        "ranaze_step3_uat": "1ab6105b7e6fd3128b68c78fde50bab824e88137f4bcfe8a03f25f89ba6b530e",
        "ranaze_step3_prd": "1ab6105b7e6fd3128b68c78fde50bab824e88137f4bcfe8a03f25f89ba6b530e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No change occurred because limits were not crossed does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            },
            {
              "id": "B",
              "text": "Option C: The process necessarily became less stable does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            },
            {
              "id": "C",
              "text": "Option D: The sample must be discarded does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No change occurred because limits were not crossed does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The process necessarily became less stable does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            },
            {
              "id": "B",
              "text": "Option B: No change occurred because limits were not crossed does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            },
            {
              "id": "C",
              "text": "Option D: The sample must be discarded does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The process necessarily became less stable does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The sample must be discarded does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            },
            {
              "id": "B",
              "text": "Option B: No change occurred because limits were not crossed does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            },
            {
              "id": "C",
              "text": "Option C: The process necessarily became less stable does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The sample must be discarded does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The centerline can never be recalculated does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            },
            {
              "id": "B",
              "text": "Option B: No change occurred because limits were not crossed does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            },
            {
              "id": "C",
              "text": "Option C: The process necessarily became less stable does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The centerline can never be recalculated does not fit the decisive finding: eight consecutive points fall below. Control charts detect nonrandom runs and shifts, not only points outside control limits."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-deep-neck-infection-airway",
      "expectedHashes": {
        "ranaze_step3_uat": "75c4906e3511d89fb7b78d6bf3164c2026b829a5f526ccc0149a872625856be2",
        "ranaze_step3_prd": "75c4906e3511d89fb7b78d6bf3164c2026b829a5f526ccc0149a872625856be2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Send him home with oral mouthwash does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            },
            {
              "id": "B",
              "text": "Option C: Perform blind oral intubation after sedation does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            },
            {
              "id": "C",
              "text": "Option D: Wait for fluctuance before treatment does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Send him home with oral mouthwash does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform blind oral intubation after sedation does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            },
            {
              "id": "B",
              "text": "Option B: Send him home with oral mouthwash does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            },
            {
              "id": "C",
              "text": "Option D: Wait for fluctuance before treatment does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform blind oral intubation after sedation does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for fluctuance before treatment does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            },
            {
              "id": "B",
              "text": "Option B: Send him home with oral mouthwash does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            },
            {
              "id": "C",
              "text": "Option C: Perform blind oral intubation after sedation does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for fluctuance before treatment does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain dental radiographs before airway planning does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            },
            {
              "id": "B",
              "text": "Option B: Send him home with oral mouthwash does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            },
            {
              "id": "C",
              "text": "Option C: Perform blind oral intubation after sedation does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain dental radiographs before airway planning does not fit the decisive finding: tongue elevation. In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-delirium-hypoactive-medication-review",
      "expectedHashes": {
        "ranaze_step3_uat": "f399c2ef3cc928d86535b7221f0e779e0788b38895e6c6eae7d577088912e860",
        "ranaze_step3_prd": "f399c2ef3cc928d86535b7221f0e779e0788b38895e6c6eae7d577088912e860"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diagnose major depression and discharge does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            },
            {
              "id": "B",
              "text": "Option C: Start a benzodiazepine nightly does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            },
            {
              "id": "C",
              "text": "Option D: Apply restraints continuously does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diagnose major depression and discharge does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start a benzodiazepine nightly does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            },
            {
              "id": "B",
              "text": "Option B: Diagnose major depression and discharge does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            },
            {
              "id": "C",
              "text": "Option D: Apply restraints continuously does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start a benzodiazepine nightly does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply restraints continuously does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            },
            {
              "id": "B",
              "text": "Option B: Diagnose major depression and discharge does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            },
            {
              "id": "C",
              "text": "Option C: Start a benzodiazepine nightly does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply restraints continuously does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin a cholinesterase inhibitor for dementia does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            },
            {
              "id": "B",
              "text": "Option B: Diagnose major depression and discharge does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            },
            {
              "id": "C",
              "text": "Option C: Start a benzodiazepine nightly does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin a cholinesterase inhibitor for dementia does not fit the decisive finding: alertness fluctuates. Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-ectopic-pregnancy-methotrexate-failure",
      "expectedHashes": {
        "ranaze_step3_uat": "b2227f4483efca8933b887ce0dc747c712ed2e33d79abc4055b2bc06997a0a8e",
        "ranaze_step3_prd": "b2227f4483efca8933b887ce0dc747c712ed2e33d79abc4055b2bc06997a0a8e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Declare treatment successful and stop follow-up does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            },
            {
              "id": "B",
              "text": "Option C: Repeat beta-hCG in one year does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            },
            {
              "id": "C",
              "text": "Option D: Begin progesterone supplementation does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Declare treatment successful and stop follow-up does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat beta-hCG in one year does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            },
            {
              "id": "B",
              "text": "Option B: Declare treatment successful and stop follow-up does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            },
            {
              "id": "C",
              "text": "Option D: Begin progesterone supplementation does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat beta-hCG in one year does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin progesterone supplementation does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            },
            {
              "id": "B",
              "text": "Option B: Declare treatment successful and stop follow-up does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            },
            {
              "id": "C",
              "text": "Option C: Repeat beta-hCG in one year does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin progesterone supplementation does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform uterine curettage as definitive tubal treatment does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            },
            {
              "id": "B",
              "text": "Option B: Declare treatment successful and stop follow-up does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            },
            {
              "id": "C",
              "text": "Option C: Repeat beta-hCG in one year does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform uterine curettage as definitive tubal treatment does not fit the decisive finding: falls 3% between treatment days 4 and 7. After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-emergency-unrepresented-consent",
      "expectedHashes": {
        "ranaze_step3_uat": "4351136cf403cd13e9c185546a1327d01247f9c1bf0f223dea81a772ba56c97b",
        "ranaze_step3_prd": "4351136cf403cd13e9c185546a1327d01247f9c1bf0f223dea81a772ba56c97b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for a court-appointed guardian does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            },
            {
              "id": "B",
              "text": "Option C: Provide comfort care because written consent is absent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            },
            {
              "id": "C",
              "text": "Option D: Ask hospital security to consent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for a court-appointed guardian does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide comfort care because written consent is absent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            },
            {
              "id": "B",
              "text": "Option B: Wait for a court-appointed guardian does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            },
            {
              "id": "C",
              "text": "Option D: Ask hospital security to consent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide comfort care because written consent is absent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask hospital security to consent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            },
            {
              "id": "B",
              "text": "Option B: Wait for a court-appointed guardian does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            },
            {
              "id": "C",
              "text": "Option C: Provide comfort care because written consent is absent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask hospital security to consent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Postpone until identity is confirmed does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            },
            {
              "id": "B",
              "text": "Option B: Wait for a court-appointed guardian does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            },
            {
              "id": "C",
              "text": "Option C: Provide comfort care because written consent is absent does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Postpone until identity is confirmed does not fit the decisive finding: will die without immediate surgery. Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-epistaxis-posterior",
      "expectedHashes": {
        "ranaze_step3_uat": "88e362a60e6952ce15e675dfdc2be1bfb7a290724368519597493be478db4615",
        "ranaze_step3_prd": "88e362a60e6952ce15e675dfdc2be1bfb7a290724368519597493be478db4615"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeated nose blowing does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            },
            {
              "id": "B",
              "text": "Option C: Discharge with petroleum jelly does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            },
            {
              "id": "C",
              "text": "Option D: Tilt the head backward and swallow blood does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeated nose blowing does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with petroleum jelly does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            },
            {
              "id": "B",
              "text": "Option B: Repeated nose blowing does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            },
            {
              "id": "C",
              "text": "Option D: Tilt the head backward and swallow blood does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with petroleum jelly does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tilt the head backward and swallow blood does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            },
            {
              "id": "B",
              "text": "Option B: Repeated nose blowing does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            },
            {
              "id": "C",
              "text": "Option C: Discharge with petroleum jelly does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tilt the head backward and swallow blood does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elective sinus CT in one month does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            },
            {
              "id": "B",
              "text": "Option B: Repeated nose blowing does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            },
            {
              "id": "C",
              "text": "Option C: Discharge with petroleum jelly does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elective sinus CT in one month does not fit the decisive finding: large clots continue to enter the throat. Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-error-disclosure",
      "expectedHashes": {
        "ranaze_step3_uat": "251fd4797f8658305409c2c24af6b2f1b92fac8e594dfba7d6dc472ba8984d99",
        "ranaze_step3_prd": "251fd4797f8658305409c2c24af6b2f1b92fac8e594dfba7d6dc472ba8984d99"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold the error because no permanent harm occurred does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            },
            {
              "id": "B",
              "text": "Option C: Blame the nurse who administered the order does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            },
            {
              "id": "C",
              "text": "Option D: Alter the record to show the intended dose does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold the error because no permanent harm occurred does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Blame the nurse who administered the order does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            },
            {
              "id": "B",
              "text": "Option B: Withhold the error because no permanent harm occurred does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            },
            {
              "id": "C",
              "text": "Option D: Alter the record to show the intended dose does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Blame the nurse who administered the order does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alter the record to show the intended dose does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            },
            {
              "id": "B",
              "text": "Option B: Withhold the error because no permanent harm occurred does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            },
            {
              "id": "C",
              "text": "Option C: Blame the nurse who administered the order does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alter the record to show the intended dose does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait until the patient obtains the chart does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            },
            {
              "id": "B",
              "text": "Option B: Withhold the error because no permanent harm occurred does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            },
            {
              "id": "C",
              "text": "Option C: Blame the nurse who administered the order does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait until the patient obtains the chart does not fit the decisive finding: ten times the intended insulin dose. Disclose clinically significant errors honestly and explain mitigation and prevention."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-falls-prevention-exercise",
      "expectedHashes": {
        "ranaze_step3_uat": "2f25001ddc302e08ea62373b0a11bc08b2aac4b745387da5851a3fdba0d3de2a",
        "ranaze_step3_prd": "2f25001ddc302e08ea62373b0a11bc08b2aac4b745387da5851a3fdba0d3de2a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine hip radiographs does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            },
            {
              "id": "B",
              "text": "Option C: Prophylactic bed rest does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            },
            {
              "id": "C",
              "text": "Option D: Daily benzodiazepine does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine hip radiographs does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prophylactic bed rest does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            },
            {
              "id": "B",
              "text": "Option B: Routine hip radiographs does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            },
            {
              "id": "C",
              "text": "Option D: Daily benzodiazepine does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prophylactic bed rest does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Daily benzodiazepine does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            },
            {
              "id": "B",
              "text": "Option B: Routine hip radiographs does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            },
            {
              "id": "C",
              "text": "Option C: Prophylactic bed rest does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Daily benzodiazepine does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A wheelchair for all mobility does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            },
            {
              "id": "B",
              "text": "Option B: Routine hip radiographs does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            },
            {
              "id": "C",
              "text": "Option C: Prophylactic bed rest does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A wheelchair for all mobility does not fit the decisive finding: impaired balance and reduced leg strength. Use structured balance and strength exercise for older adults at increased fall risk."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-handoff-readback",
      "expectedHashes": {
        "ranaze_step3_uat": "dc53b17561df1c997a33abd37f43fe63bc5d6de13ec5c0fe1d45f155d6ab41f5",
        "ranaze_step3_prd": "dc53b17561df1c997a33abd37f43fe63bc5d6de13ec5c0fe1d45f155d6ab41f5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ban all speech during resuscitation does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            },
            {
              "id": "B",
              "text": "Option C: Add a longer incident form does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            },
            {
              "id": "C",
              "text": "Option D: Ask only senior staff to listen does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ban all speech during resuscitation does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Add a longer incident form does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            },
            {
              "id": "B",
              "text": "Option B: Ban all speech during resuscitation does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            },
            {
              "id": "C",
              "text": "Option D: Ask only senior staff to listen does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Add a longer incident form does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask only senior staff to listen does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            },
            {
              "id": "B",
              "text": "Option B: Ban all speech during resuscitation does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            },
            {
              "id": "C",
              "text": "Option C: Add a longer incident form does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask only senior staff to listen does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay all treatment until orders are typed does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            },
            {
              "id": "B",
              "text": "Option B: Ban all speech during resuscitation does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            },
            {
              "id": "C",
              "text": "Option C: Add a longer incident form does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay all treatment until orders are typed does not fit the decisive finding: neither repeats the order. Use read-back and confirmation for critical verbal orders in high-risk settings."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-hereditary-angioedema",
      "expectedHashes": {
        "ranaze_step3_uat": "d7648fcef72015d21d7b14417bae8db0d93a74043bb15db09ebaafee4730434c",
        "ranaze_step3_prd": "d7648fcef72015d21d7b14417bae8db0d93a74043bb15db09ebaafee4730434c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diphenhydramine alone does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            },
            {
              "id": "B",
              "text": "Option C: High-dose aspirin does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            },
            {
              "id": "C",
              "text": "Option D: Epinephrine as the only definitive therapy does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diphenhydramine alone does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose aspirin does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine alone does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            },
            {
              "id": "C",
              "text": "Option D: Epinephrine as the only definitive therapy does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose aspirin does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Epinephrine as the only definitive therapy does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine alone does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            },
            {
              "id": "C",
              "text": "Option C: High-dose aspirin does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Epinephrine as the only definitive therapy does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral antibiotics does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            },
            {
              "id": "B",
              "text": "Option B: Diphenhydramine alone does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            },
            {
              "id": "C",
              "text": "Option C: High-dose aspirin does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral antibiotics does not fit the decisive finding: persistently low C4. Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-hypercalcemic-crisis-fluids",
      "expectedHashes": {
        "ranaze_step3_uat": "3f18a7662d80a49e123b9aeaca0d8b8375b0308096166de2d85a2cc708b908cc",
        "ranaze_step3_prd": "3f18a7662d80a49e123b9aeaca0d8b8375b0308096166de2d85a2cc708b908cc"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thiazide diuretic does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            },
            {
              "id": "B",
              "text": "Option C: Fluid restriction does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            },
            {
              "id": "C",
              "text": "Option D: Oral calcium supplementation does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thiazide diuretic does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fluid restriction does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            },
            {
              "id": "B",
              "text": "Option B: Thiazide diuretic does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            },
            {
              "id": "C",
              "text": "Option D: Oral calcium supplementation does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fluid restriction does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral calcium supplementation does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            },
            {
              "id": "B",
              "text": "Option B: Thiazide diuretic does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            },
            {
              "id": "C",
              "text": "Option C: Fluid restriction does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral calcium supplementation does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation until parathyroid hormone returns does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            },
            {
              "id": "B",
              "text": "Option B: Thiazide diuretic does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            },
            {
              "id": "C",
              "text": "Option C: Fluid restriction does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation until parathyroid hormone returns does not fit the decisive finding: corrected calcium of 15.8 mg/dL. Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-impaired-colleague-reporting",
      "expectedHashes": {
        "ranaze_step3_uat": "983192de3a47a2af12f77c9ed7e688c089d44a05fbcb4db21b02b26ed4b582fe",
        "ranaze_step3_prd": "983192de3a47a2af12f77c9ed7e688c089d44a05fbcb4db21b02b26ed4b582fe"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obey because the surgeon is senior does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            },
            {
              "id": "B",
              "text": "Option C: Wait to see whether an error occurs does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            },
            {
              "id": "C",
              "text": "Option D: Post anonymously on social media does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obey because the surgeon is senior does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait to see whether an error occurs does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            },
            {
              "id": "B",
              "text": "Option B: Obey because the surgeon is senior does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            },
            {
              "id": "C",
              "text": "Option D: Post anonymously on social media does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait to see whether an error occurs does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Post anonymously on social media does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            },
            {
              "id": "B",
              "text": "Option B: Obey because the surgeon is senior does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            },
            {
              "id": "C",
              "text": "Option C: Wait to see whether an error occurs does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Post anonymously on social media does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Confront the surgeon after the case only does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            },
            {
              "id": "B",
              "text": "Option B: Obey because the surgeon is senior does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            },
            {
              "id": "C",
              "text": "Option C: Wait to see whether an error occurs does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Confront the surgeon after the case only does not fit the decisive finding: slurred speech. Patient safety overrides hierarchy when a clinician appears impaired during care."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-language-interpreter",
      "expectedHashes": {
        "ranaze_step3_uat": "94e71d0a8e57d5bfb131a9e22c7c446f8d801cc6518c82c26f29e37de673033b",
        "ranaze_step3_prd": "94e71d0a8e57d5bfb131a9e22c7c446f8d801cc6518c82c26f29e37de673033b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use the daughter because she is family does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            },
            {
              "id": "B",
              "text": "Option C: Obtain a signature without further discussion does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            },
            {
              "id": "C",
              "text": "Option D: Cancel surgery permanently does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use the daughter because she is family does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a signature without further discussion does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            },
            {
              "id": "B",
              "text": "Option B: Use the daughter because she is family does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            },
            {
              "id": "C",
              "text": "Option D: Cancel surgery permanently does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a signature without further discussion does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cancel surgery permanently does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            },
            {
              "id": "B",
              "text": "Option B: Use the daughter because she is family does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a signature without further discussion does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cancel surgery permanently does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask another patient to interpret does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            },
            {
              "id": "B",
              "text": "Option B: Use the daughter because she is family does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a signature without further discussion does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask another patient to interpret does not fit the decisive finding: omits discussion of infertility. Use a qualified medical interpreter for consequential clinical communication and informed consent."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-lung-cancer-screening-ldct",
      "expectedHashes": {
        "ranaze_step3_uat": "81802d0cf0c7d9cde944ba8f9a613a269144aa46f1aa49a44559dafbd98adfcc",
        "ranaze_step3_prd": "81802d0cf0c7d9cde944ba8f9a613a269144aa46f1aa49a44559dafbd98adfcc"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Annual chest radiography does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            },
            {
              "id": "B",
              "text": "Option C: Sputum cytology every 6 months does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            },
            {
              "id": "C",
              "text": "Option D: No screening until symptoms develop does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Annual chest radiography does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sputum cytology every 6 months does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            },
            {
              "id": "B",
              "text": "Option B: Annual chest radiography does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            },
            {
              "id": "C",
              "text": "Option D: No screening until symptoms develop does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sputum cytology every 6 months does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No screening until symptoms develop does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            },
            {
              "id": "B",
              "text": "Option B: Annual chest radiography does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            },
            {
              "id": "C",
              "text": "Option C: Sputum cytology every 6 months does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No screening until symptoms develop does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "One-time contrast chest CT only does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            },
            {
              "id": "B",
              "text": "Option B: Annual chest radiography does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            },
            {
              "id": "C",
              "text": "Option C: Sputum cytology every 6 months does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "One-time contrast chest CT only does not fit the decisive finding: 28-pack-year smoking history. Use annual low-dose CT, not chest radiography, for eligible high-risk adults."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-malignant-otitis-externa",
      "expectedHashes": {
        "ranaze_step3_uat": "ddcb4ff2066270fbd7532b90898d49b01051a399c9f2fb9aa2cd6d9c5f7c4244",
        "ranaze_step3_prd": "ddcb4ff2066270fbd7532b90898d49b01051a399c9f2fb9aa2cd6d9c5f7c4244"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical anesthetic drops alone does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            },
            {
              "id": "B",
              "text": "Option C: Routine cerumen removal and discharge does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            },
            {
              "id": "C",
              "text": "Option D: Oral amoxicillin for 3 days does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical anesthetic drops alone does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine cerumen removal and discharge does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            },
            {
              "id": "B",
              "text": "Option B: Topical anesthetic drops alone does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            },
            {
              "id": "C",
              "text": "Option D: Oral amoxicillin for 3 days does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine cerumen removal and discharge does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral amoxicillin for 3 days does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            },
            {
              "id": "B",
              "text": "Option B: Topical anesthetic drops alone does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            },
            {
              "id": "C",
              "text": "Option C: Routine cerumen removal and discharge does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral amoxicillin for 3 days does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation because he is afebrile does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            },
            {
              "id": "B",
              "text": "Option B: Topical anesthetic drops alone does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            },
            {
              "id": "C",
              "text": "Option C: Routine cerumen removal and discharge does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation because he is afebrile does not fit the decisive finding: granulation tissue. Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-migraine-aura-contraception",
      "expectedHashes": {
        "ranaze_step3_uat": "f46f0bafe01be27d42515dd2a2ef07eb60421c0775585a2b4841ac7d64ba9337",
        "ranaze_step3_prd": "f46f0bafe01be27d42515dd2a2ef07eb60421c0775585a2b4841ac7d64ba9337"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Combined estrogen-progestin pill does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            },
            {
              "id": "B",
              "text": "Option C: Combined hormonal patch does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            },
            {
              "id": "C",
              "text": "Option D: Combined vaginal ring does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Combined estrogen-progestin pill does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Combined hormonal patch does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            },
            {
              "id": "B",
              "text": "Option B: Combined estrogen-progestin pill does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            },
            {
              "id": "C",
              "text": "Option D: Combined vaginal ring does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Combined hormonal patch does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Combined vaginal ring does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            },
            {
              "id": "B",
              "text": "Option B: Combined estrogen-progestin pill does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            },
            {
              "id": "C",
              "text": "Option C: Combined hormonal patch does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Combined vaginal ring does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose estrogen injection does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            },
            {
              "id": "B",
              "text": "Option B: Combined estrogen-progestin pill does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            },
            {
              "id": "C",
              "text": "Option C: Combined hormonal patch does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose estrogen injection does not fit the decisive finding: migraine with visual aura. Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-minor-confidential-sti-care",
      "expectedHashes": {
        "ranaze_step3_uat": "d87b3be7f8307f5816dda4aa94453f1d640a2960b966e59d73351a2c64306c0d",
        "ranaze_step3_prd": "d87b3be7f8307f5816dda4aa94453f1d640a2960b966e59d73351a2c64306c0d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refuse testing without parental permission does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            },
            {
              "id": "B",
              "text": "Option C: Call the parent before obtaining specimens does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            },
            {
              "id": "C",
              "text": "Option D: Notify the school does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refuse testing without parental permission does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Call the parent before obtaining specimens does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            },
            {
              "id": "B",
              "text": "Option B: Refuse testing without parental permission does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            },
            {
              "id": "C",
              "text": "Option D: Notify the school does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Call the parent before obtaining specimens does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Notify the school does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            },
            {
              "id": "B",
              "text": "Option B: Refuse testing without parental permission does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            },
            {
              "id": "C",
              "text": "Option C: Call the parent before obtaining specimens does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Notify the school does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Report consensual activity as abuse solely because she is a minor does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            },
            {
              "id": "B",
              "text": "Option B: Refuse testing without parental permission does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            },
            {
              "id": "C",
              "text": "Option C: Call the parent before obtaining specimens does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Report consensual activity as abuse solely because she is a minor does not fit the decisive finding: local law permits minors to consent to STI care. Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-necrotizing-fasciitis-surgery",
      "expectedHashes": {
        "ranaze_step3_uat": "4c3d29f47411af9884ff3284cccb176b9ccf1dfe4cd16b2382b5e36ec6129319",
        "ranaze_step3_prd": "4c3d29f47411af9884ff3284cccb176b9ccf1dfe4cd16b2382b5e36ec6129319"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for CT confirmation does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            },
            {
              "id": "B",
              "text": "Option C: Incision and drainage at the bedside only does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            },
            {
              "id": "C",
              "text": "Option D: Topical antibiotics does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for CT confirmation does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Incision and drainage at the bedside only does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            },
            {
              "id": "B",
              "text": "Option B: Wait for CT confirmation does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            },
            {
              "id": "C",
              "text": "Option D: Topical antibiotics does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Incision and drainage at the bedside only does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical antibiotics does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            },
            {
              "id": "B",
              "text": "Option B: Wait for CT confirmation does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            },
            {
              "id": "C",
              "text": "Option C: Incision and drainage at the bedside only does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical antibiotics does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe response for 24 hours does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            },
            {
              "id": "B",
              "text": "Option B: Wait for CT confirmation does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            },
            {
              "id": "C",
              "text": "Option C: Incision and drainage at the bedside only does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe response for 24 hours does not fit the decisive finding: pain far out of proportion. Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-osteoporosis-screening-dxa",
      "expectedHashes": {
        "ranaze_step3_uat": "c43e048b4b4c03d0942113df7dee33005a0789465035c640e2a4e3cb3b500c36",
        "ranaze_step3_prd": "c43e048b4b4c03d0942113df7dee33005a0789465035c640e2a4e3cb3b500c36"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plain radiographs of the spine does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            },
            {
              "id": "B",
              "text": "Option C: Serum calcium alone does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            },
            {
              "id": "C",
              "text": "Option D: No screening without fracture does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plain radiographs of the spine does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum calcium alone does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the spine does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            },
            {
              "id": "C",
              "text": "Option D: No screening without fracture does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum calcium alone does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No screening without fracture does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the spine does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            },
            {
              "id": "C",
              "text": "Option C: Serum calcium alone does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No screening without fracture does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bone biopsy does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the spine does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            },
            {
              "id": "C",
              "text": "Option C: Serum calcium alone does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bone biopsy does not fit the decisive finding: 66-year-old woman. Screen women age 65 or older for osteoporosis with DXA."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-pelvic-inflammatory-disease-outpatient",
      "expectedHashes": {
        "ranaze_step3_uat": "af312c938d7fe83bed3c48927d0d832c6a55516a94ca186c12754666297d232a",
        "ranaze_step3_prd": "af312c938d7fe83bed3c48927d0d832c6a55516a94ca186c12754666297d232a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for gonorrhea culture confirmation does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            },
            {
              "id": "B",
              "text": "Option C: Fluconazole alone does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            },
            {
              "id": "C",
              "text": "Option D: Immediate hysterectomy does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for gonorrhea culture confirmation does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fluconazole alone does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for gonorrhea culture confirmation does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            },
            {
              "id": "C",
              "text": "Option D: Immediate hysterectomy does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fluconazole alone does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate hysterectomy does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for gonorrhea culture confirmation does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            },
            {
              "id": "C",
              "text": "Option C: Fluconazole alone does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate hysterectomy does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Azithromycin single dose alone does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for gonorrhea culture confirmation does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            },
            {
              "id": "C",
              "text": "Option C: Fluconazole alone does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Azithromycin single dose alone does not fit the decisive finding: cervical motion tenderness. Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-peritonsillar-abscess-drainage",
      "expectedHashes": {
        "ranaze_step3_uat": "96a56d67f0e011953791f4b33cd2c666e291d60d742d82d360ba3c06bcacf5b1",
        "ranaze_step3_prd": "96a56d67f0e011953791f4b33cd2c666e291d60d742d82d360ba3c06bcacf5b1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Rapid streptococcal testing alone does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            },
            {
              "id": "B",
              "text": "Option C: Discharge with an antihistamine does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            },
            {
              "id": "C",
              "text": "Option D: Immediate tonsil radiation does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Rapid streptococcal testing alone does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge with an antihistamine does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            },
            {
              "id": "B",
              "text": "Option B: Rapid streptococcal testing alone does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            },
            {
              "id": "C",
              "text": "Option D: Immediate tonsil radiation does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge with an antihistamine does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate tonsil radiation does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            },
            {
              "id": "B",
              "text": "Option B: Rapid streptococcal testing alone does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            },
            {
              "id": "C",
              "text": "Option C: Discharge with an antihistamine does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate tonsil radiation does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe without airway assessment does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            },
            {
              "id": "B",
              "text": "Option B: Rapid streptococcal testing alone does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            },
            {
              "id": "C",
              "text": "Option C: Discharge with an antihistamine does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe without airway assessment does not fit the decisive finding: deviation of the uvula. Peritonsillar abscess requires source control and antibiotics, with airway assessment first."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-pheochromocytoma-alpha-before-beta",
      "expectedHashes": {
        "ranaze_step3_uat": "0fbe2ba80bb2c57607482ba8d3b9ba4dde814a6e18314771f4e7a78ca2360540",
        "ranaze_step3_prd": "0fbe2ba80bb2c57607482ba8d3b9ba4dde814a6e18314771f4e7a78ca2360540"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin propranolol before alpha blockade does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            },
            {
              "id": "B",
              "text": "Option C: Proceed directly to surgery without preparation does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            },
            {
              "id": "C",
              "text": "Option D: Restrict salt and fluid severely does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin propranolol before alpha blockade does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly to surgery without preparation does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            },
            {
              "id": "B",
              "text": "Option B: Begin propranolol before alpha blockade does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            },
            {
              "id": "C",
              "text": "Option D: Restrict salt and fluid severely does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly to surgery without preparation does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restrict salt and fluid severely does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            },
            {
              "id": "B",
              "text": "Option B: Begin propranolol before alpha blockade does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            },
            {
              "id": "C",
              "text": "Option C: Proceed directly to surgery without preparation does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restrict salt and fluid severely does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with levothyroxine does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            },
            {
              "id": "B",
              "text": "Option B: Begin propranolol before alpha blockade does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            },
            {
              "id": "C",
              "text": "Option C: Proceed directly to surgery without preparation does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with levothyroxine does not fit the decisive finding: elevated plasma metanephrines. For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-postmenopausal-bleeding-biopsy",
      "expectedHashes": {
        "ranaze_step3_uat": "4182491297152911acc501e7a60c4894eedde90bd0c89a341d2fda62f0ba52f4",
        "ranaze_step3_prd": "4182491297152911acc501e7a60c4894eedde90bd0c89a341d2fda62f0ba52f4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassurance that bleeding is expected does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            },
            {
              "id": "B",
              "text": "Option C: Serum CA-125 alone does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            },
            {
              "id": "C",
              "text": "Option D: Empiric antibiotics does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassurance that bleeding is expected does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum CA-125 alone does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            },
            {
              "id": "B",
              "text": "Option B: Reassurance that bleeding is expected does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            },
            {
              "id": "C",
              "text": "Option D: Empiric antibiotics does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum CA-125 alone does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Empiric antibiotics does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            },
            {
              "id": "B",
              "text": "Option B: Reassurance that bleeding is expected does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            },
            {
              "id": "C",
              "text": "Option C: Serum CA-125 alone does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Empiric antibiotics does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat examination in one year does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            },
            {
              "id": "B",
              "text": "Option B: Reassurance that bleeding is expected does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            },
            {
              "id": "C",
              "text": "Option C: Serum CA-125 alone does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat examination in one year does not fit the decisive finding: new painless vaginal bleeding 11 years after menopause. Evaluate postmenopausal bleeding promptly for endometrial neoplasia."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-postpartum-endometritis",
      "expectedHashes": {
        "ranaze_step3_uat": "7767b27a0a6ec41c8c9a8f5a07e9309f1addf0a4f9afddf3267b581a12f02d03",
        "ranaze_step3_prd": "7767b27a0a6ec41c8c9a8f5a07e9309f1addf0a4f9afddf3267b581a12f02d03"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral fluconazole does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            },
            {
              "id": "B",
              "text": "Option C: Incision drainage despite a clean wound does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            },
            {
              "id": "C",
              "text": "Option D: Anticoagulation alone does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral fluconazole does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Incision drainage despite a clean wound does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            },
            {
              "id": "B",
              "text": "Option B: Oral fluconazole does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            },
            {
              "id": "C",
              "text": "Option D: Anticoagulation alone does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Incision drainage despite a clean wound does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anticoagulation alone does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            },
            {
              "id": "B",
              "text": "Option B: Oral fluconazole does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            },
            {
              "id": "C",
              "text": "Option C: Incision drainage despite a clean wound does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anticoagulation alone does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation without antibiotics does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            },
            {
              "id": "B",
              "text": "Option B: Oral fluconazole does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            },
            {
              "id": "C",
              "text": "Option C: Incision drainage despite a clean wound does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation without antibiotics does not fit the decisive finding: uterine fundal tenderness. Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-postpartum-psychosis-emergency",
      "expectedHashes": {
        "ranaze_step3_uat": "57bd3b54c68940b32c298994a66b97dad80fccffa7def1bf1c854e09502d9705",
        "ranaze_step3_prd": "57bd3b54c68940b32c298994a66b97dad80fccffa7def1bf1c854e09502d9705"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine follow-up in 6 weeks does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            },
            {
              "id": "B",
              "text": "Option C: Reassurance that postpartum blues will resolve does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            },
            {
              "id": "C",
              "text": "Option D: Psychotherapy alone at home does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine follow-up in 6 weeks does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassurance that postpartum blues will resolve does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            },
            {
              "id": "B",
              "text": "Option B: Routine follow-up in 6 weeks does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            },
            {
              "id": "C",
              "text": "Option D: Psychotherapy alone at home does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassurance that postpartum blues will resolve does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Psychotherapy alone at home does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            },
            {
              "id": "B",
              "text": "Option B: Routine follow-up in 6 weeks does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            },
            {
              "id": "C",
              "text": "Option C: Reassurance that postpartum blues will resolve does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Psychotherapy alone at home does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Allow unsupervised infant care to preserve bonding does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            },
            {
              "id": "B",
              "text": "Option B: Routine follow-up in 6 weeks does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            },
            {
              "id": "C",
              "text": "Option C: Reassurance that postpartum blues will resolve does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Allow unsupervised infant care to preserve bonding does not fit the decisive finding: reports a command to drown him. Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-preeclampsia-severe-delivery",
      "expectedHashes": {
        "ranaze_step3_uat": "78e92d8f07dabb1c023e5660b1dc3fc6e65fd8163d9311ac44e870891187eacb",
        "ranaze_step3_prd": "78e92d8f07dabb1c023e5660b1dc3fc6e65fd8163d9311ac44e870891187eacb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Expectant outpatient management until 40 weeks does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            },
            {
              "id": "B",
              "text": "Option C: Tocolysis and discharge does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            },
            {
              "id": "C",
              "text": "Option D: Aspirin as sole treatment does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Expectant outpatient management until 40 weeks does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tocolysis and discharge does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            },
            {
              "id": "B",
              "text": "Option B: Expectant outpatient management until 40 weeks does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            },
            {
              "id": "C",
              "text": "Option D: Aspirin as sole treatment does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tocolysis and discharge does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspirin as sole treatment does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            },
            {
              "id": "B",
              "text": "Option B: Expectant outpatient management until 40 weeks does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            },
            {
              "id": "C",
              "text": "Option C: Tocolysis and discharge does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspirin as sole treatment does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat laboratory testing in one month does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            },
            {
              "id": "B",
              "text": "Option B: Expectant outpatient management until 40 weeks does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            },
            {
              "id": "C",
              "text": "Option C: Tocolysis and discharge does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat laboratory testing in one month does not fit the decisive finding: platelets of 82,000/mm3. Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-priapism-aspiration",
      "expectedHashes": {
        "ranaze_step3_uat": "cf3cccdc5101a57486fd5352ac0186c81fd8ead346cc87d1e303c7eb99cd71f0",
        "ranaze_step3_prd": "cf3cccdc5101a57486fd5352ac0186c81fd8ead346cc87d1e303c7eb99cd71f0"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation until 24 hours does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            },
            {
              "id": "B",
              "text": "Option C: Oral sildenafil does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            },
            {
              "id": "C",
              "text": "Option D: Apply a warm compress only does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation until 24 hours does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral sildenafil does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            },
            {
              "id": "B",
              "text": "Option B: Observation until 24 hours does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            },
            {
              "id": "C",
              "text": "Option D: Apply a warm compress only does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral sildenafil does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply a warm compress only does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            },
            {
              "id": "B",
              "text": "Option B: Observation until 24 hours does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            },
            {
              "id": "C",
              "text": "Option C: Oral sildenafil does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply a warm compress only does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elective penile Doppler next month does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            },
            {
              "id": "B",
              "text": "Option B: Observation until 24 hours does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            },
            {
              "id": "C",
              "text": "Option C: Oral sildenafil does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elective penile Doppler next month does not fit the decisive finding: cavernosal blood gas shows acidosis and hypoxia. Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-root-cause-analysis",
      "expectedHashes": {
        "ranaze_step3_uat": "5f404cf4d46bc48a2aecc22e8b4037ba46ae4b35daea4321eacfc6bc0d2cbac3",
        "ranaze_step3_prd": "5f404cf4d46bc48a2aecc22e8b4037ba46ae4b35daea4321eacfc6bc0d2cbac3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Retrain the last nurse only does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            },
            {
              "id": "B",
              "text": "Option C: Ask staff to be more careful does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            },
            {
              "id": "C",
              "text": "Option D: Keep the vials together for convenience does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Retrain the last nurse only does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask staff to be more careful does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            },
            {
              "id": "B",
              "text": "Option B: Retrain the last nurse only does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            },
            {
              "id": "C",
              "text": "Option D: Keep the vials together for convenience does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask staff to be more careful does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Keep the vials together for convenience does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            },
            {
              "id": "B",
              "text": "Option B: Retrain the last nurse only does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            },
            {
              "id": "C",
              "text": "Option C: Ask staff to be more careful does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Keep the vials together for convenience does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Suppress incident reporting does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            },
            {
              "id": "B",
              "text": "Option B: Retrain the last nurse only does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            },
            {
              "id": "C",
              "text": "Option C: Ask staff to be more careful does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Suppress incident reporting does not fit the decisive finding: vials had similar labels. Use systems analysis and strong process controls rather than education or blame alone after a serious safety event."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-serotonin-syndrome-linezolid",
      "expectedHashes": {
        "ranaze_step3_uat": "e79e0a0361bc096f1a260459d2a0775557b94e9e5d573d19626262e35e97676b",
        "ranaze_step3_prd": "e79e0a0361bc096f1a260459d2a0775557b94e9e5d573d19626262e35e97676b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restart fluoxetine to avoid withdrawal does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            },
            {
              "id": "B",
              "text": "Option C: Continue linezolid and give dantrolene does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            },
            {
              "id": "C",
              "text": "Option D: Perform hemodialysis to remove both drugs does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restart fluoxetine to avoid withdrawal does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue linezolid and give dantrolene does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            },
            {
              "id": "B",
              "text": "Option B: Restart fluoxetine to avoid withdrawal does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            },
            {
              "id": "C",
              "text": "Option D: Perform hemodialysis to remove both drugs does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue linezolid and give dantrolene does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform hemodialysis to remove both drugs does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            },
            {
              "id": "B",
              "text": "Option B: Restart fluoxetine to avoid withdrawal does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            },
            {
              "id": "C",
              "text": "Option C: Continue linezolid and give dantrolene does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform hemodialysis to remove both drugs does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give bromocriptine and observe does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            },
            {
              "id": "B",
              "text": "Option B: Restart fluoxetine to avoid withdrawal does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            },
            {
              "id": "C",
              "text": "Option C: Continue linezolid and give dantrolene does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give bromocriptine and observe does not fit the decisive finding: inducible ankle clonus. Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-serum-sickness-like",
      "expectedHashes": {
        "ranaze_step3_uat": "59f6011500b67573164e1304fc293891439e2059874498d1e81ea897f6a08a68",
        "ranaze_step3_prd": "59f6011500b67573164e1304fc293891439e2059874498d1e81ea897f6a08a68"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue cefaclor to complete the course does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            },
            {
              "id": "B",
              "text": "Option C: Administer epinephrine for isolated delayed symptoms does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            },
            {
              "id": "C",
              "text": "Option D: Begin lifelong immunoglobulin replacement does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue cefaclor to complete the course does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer epinephrine for isolated delayed symptoms does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            },
            {
              "id": "B",
              "text": "Option B: Continue cefaclor to complete the course does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            },
            {
              "id": "C",
              "text": "Option D: Begin lifelong immunoglobulin replacement does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer epinephrine for isolated delayed symptoms does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin lifelong immunoglobulin replacement does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            },
            {
              "id": "B",
              "text": "Option B: Continue cefaclor to complete the course does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            },
            {
              "id": "C",
              "text": "Option C: Administer epinephrine for isolated delayed symptoms does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin lifelong immunoglobulin replacement does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform emergent skin debridement does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            },
            {
              "id": "B",
              "text": "Option B: Continue cefaclor to complete the course does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            },
            {
              "id": "C",
              "text": "Option C: Administer epinephrine for isolated delayed symptoms does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform emergent skin debridement does not fit the decisive finding: 9 days after starting cefaclor. For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-shoulder-dystocia-mcRoberts",
      "expectedHashes": {
        "ranaze_step3_uat": "36a1fa04b1969df01031c0e7e84db86356a4edb0b50ab7dd734de933c376e332",
        "ranaze_step3_prd": "36a1fa04b1969df01031c0e7e84db86356a4edb0b50ab7dd734de933c376e332"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fundal pressure does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            },
            {
              "id": "B",
              "text": "Option C: Immediate cesarean delivery does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            },
            {
              "id": "C",
              "text": "Option D: Forceful traction on the fetal head does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fundal pressure does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate cesarean delivery does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            },
            {
              "id": "B",
              "text": "Option B: Fundal pressure does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            },
            {
              "id": "C",
              "text": "Option D: Forceful traction on the fetal head does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate cesarean delivery does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Forceful traction on the fetal head does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            },
            {
              "id": "B",
              "text": "Option B: Fundal pressure does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            },
            {
              "id": "C",
              "text": "Option C: Immediate cesarean delivery does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Forceful traction on the fetal head does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vacuum extraction of the delivered head does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            },
            {
              "id": "B",
              "text": "Option B: Fundal pressure does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            },
            {
              "id": "C",
              "text": "Option C: Immediate cesarean delivery does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vacuum extraction of the delivered head does not fit the decisive finding: head delivers and retracts. Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-sjs-ten-drug-withdrawal",
      "expectedHashes": {
        "ranaze_step3_uat": "42f79ee2e23f9a81e6d51f441d606fb873dbbbe31e25e0b489f9d4ea5bab18e8",
        "ranaze_step3_prd": "42f79ee2e23f9a81e6d51f441d606fb873dbbbe31e25e0b489f9d4ea5bab18e8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue lamotrigine with an antihistamine does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            },
            {
              "id": "B",
              "text": "Option C: Debride all detached epidermis at bedside does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe topical acne therapy does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue lamotrigine with an antihistamine does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Debride all detached epidermis at bedside does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            },
            {
              "id": "B",
              "text": "Option B: Continue lamotrigine with an antihistamine does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe topical acne therapy does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Debride all detached epidermis at bedside does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe topical acne therapy does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            },
            {
              "id": "B",
              "text": "Option B: Continue lamotrigine with an antihistamine does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            },
            {
              "id": "C",
              "text": "Option C: Debride all detached epidermis at bedside does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe topical acne therapy does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge after oral fluids does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            },
            {
              "id": "B",
              "text": "Option B: Continue lamotrigine with an antihistamine does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            },
            {
              "id": "C",
              "text": "Option C: Debride all detached epidermis at bedside does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge after oral fluids does not fit the decisive finding: oral erosions. Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-sudden-sensorineural-hearing-loss",
      "expectedHashes": {
        "ranaze_step3_uat": "1959e0cf2d0e1f1284e7bab876441104a09caf6d2d069288f63443cc07669787",
        "ranaze_step3_prd": "1959e0cf2d0e1f1284e7bab876441104a09caf6d2d069288f63443cc07669787"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cerumen irrigation does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            },
            {
              "id": "B",
              "text": "Option C: Routine follow-up in 3 months does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            },
            {
              "id": "C",
              "text": "Option D: Oral antibiotics for otitis media does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cerumen irrigation does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine follow-up in 3 months does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            },
            {
              "id": "B",
              "text": "Option B: Cerumen irrigation does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            },
            {
              "id": "C",
              "text": "Option D: Oral antibiotics for otitis media does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine follow-up in 3 months does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral antibiotics for otitis media does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            },
            {
              "id": "B",
              "text": "Option B: Cerumen irrigation does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            },
            {
              "id": "C",
              "text": "Option C: Routine follow-up in 3 months does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral antibiotics for otitis media does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassurance that normal otoscopy excludes urgency does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            },
            {
              "id": "B",
              "text": "Option B: Cerumen irrigation does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            },
            {
              "id": "C",
              "text": "Option C: Routine follow-up in 3 months does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassurance that normal otoscopy excludes urgency does not fit the decisive finding: Weber testing lateralizes to the right. Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-testicular-torsion-exploration",
      "expectedHashes": {
        "ranaze_step3_uat": "9b82eb5bdd88fda93c5cac5becfcaa2bacf6f9c10be157e201378315708d0fc5",
        "ranaze_step3_prd": "9b82eb5bdd88fda93c5cac5becfcaa2bacf6f9c10be157e201378315708d0fc5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for outpatient ultrasonography does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            },
            {
              "id": "B",
              "text": "Option C: Treat epididymitis with oral antibiotics does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            },
            {
              "id": "C",
              "text": "Option D: Needle aspiration does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for outpatient ultrasonography does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat epididymitis with oral antibiotics does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for outpatient ultrasonography does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            },
            {
              "id": "C",
              "text": "Option D: Needle aspiration does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat epididymitis with oral antibiotics does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Needle aspiration does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for outpatient ultrasonography does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            },
            {
              "id": "C",
              "text": "Option C: Treat epididymitis with oral antibiotics does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Needle aspiration does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassess after 24 hours does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            },
            {
              "id": "B",
              "text": "Option B: Wait for outpatient ultrasonography does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            },
            {
              "id": "C",
              "text": "Option C: Treat epididymitis with oral antibiotics does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassess after 24 hours does not fit the decisive finding: absent cremasteric reflex. When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-thyroid-storm-treatment",
      "expectedHashes": {
        "ranaze_step3_uat": "91f44ebbb58cebbd3c9197ab979eb6db9bdc4540ccc667b95cf95143759542d9",
        "ranaze_step3_prd": "91f44ebbb58cebbd3c9197ab979eb6db9bdc4540ccc667b95cf95143759542d9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Iodine before thionamide does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            },
            {
              "id": "B",
              "text": "Option C: Levothyroxine and aspirin does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            },
            {
              "id": "C",
              "text": "Option D: Radioactive iodine as immediate monotherapy does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Iodine before thionamide does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Levothyroxine and aspirin does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            },
            {
              "id": "B",
              "text": "Option B: Iodine before thionamide does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            },
            {
              "id": "C",
              "text": "Option D: Radioactive iodine as immediate monotherapy does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Levothyroxine and aspirin does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radioactive iodine as immediate monotherapy does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            },
            {
              "id": "B",
              "text": "Option B: Iodine before thionamide does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            },
            {
              "id": "C",
              "text": "Option C: Levothyroxine and aspirin does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radioactive iodine as immediate monotherapy does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation until thyroid tests return does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            },
            {
              "id": "B",
              "text": "Option B: Iodine before thionamide does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            },
            {
              "id": "C",
              "text": "Option C: Levothyroxine and aspirin does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation until thyroid tests return does not fit the decisive finding: fever of 40 C. In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-torsion-surgery",
      "expectedHashes": {
        "ranaze_step3_uat": "f1fe1ad9b269009298289eab5bd3f0ee68c5f07f0afee5c80c908a629ddf6048",
        "ranaze_step3_prd": "f1fe1ad9b269009298289eab5bd3f0ee68c5f07f0afee5c80c908a629ddf6048"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge because arterial flow excludes torsion does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            },
            {
              "id": "B",
              "text": "Option C: Repeat ultrasonography in 6 months does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            },
            {
              "id": "C",
              "text": "Option D: Methotrexate does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge because arterial flow excludes torsion does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat ultrasonography in 6 months does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            },
            {
              "id": "B",
              "text": "Option B: Discharge because arterial flow excludes torsion does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            },
            {
              "id": "C",
              "text": "Option D: Methotrexate does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat ultrasonography in 6 months does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Methotrexate does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            },
            {
              "id": "B",
              "text": "Option B: Discharge because arterial flow excludes torsion does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            },
            {
              "id": "C",
              "text": "Option C: Repeat ultrasonography in 6 months does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Methotrexate does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Endometrial biopsy does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            },
            {
              "id": "B",
              "text": "Option B: Discharge because arterial flow excludes torsion does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            },
            {
              "id": "C",
              "text": "Option C: Repeat ultrasonography in 6 months does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Endometrial biopsy does not fit the decisive finding: sudden severe unilateral pelvic pain. Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high."
        }
      }
    },
    {
      "externalId": "gap-d4-20260731-wrong-patient-near-miss",
      "expectedHashes": {
        "ranaze_step3_uat": "1de347c932001dd7e471066bc4d50c640d16acf269baa78c3082242d14e171ed",
        "ranaze_step3_prd": "1de347c932001dd7e471066bc4d50c640d16acf269baa78c3082242d14e171ed"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Take no action because no injury occurred does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            },
            {
              "id": "B",
              "text": "Option C: Discipline the nurse without reviewing the process does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            },
            {
              "id": "C",
              "text": "Option D: Disable barcode alerts does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Take no action because no injury occurred does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discipline the nurse without reviewing the process does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            },
            {
              "id": "B",
              "text": "Option B: Take no action because no injury occurred does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            },
            {
              "id": "C",
              "text": "Option D: Disable barcode alerts does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discipline the nurse without reviewing the process does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Disable barcode alerts does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            },
            {
              "id": "B",
              "text": "Option B: Take no action because no injury occurred does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            },
            {
              "id": "C",
              "text": "Option C: Discipline the nurse without reviewing the process does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Disable barcode alerts does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Move only these two patients and close the review does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            },
            {
              "id": "B",
              "text": "Option B: Take no action because no injury occurred does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            },
            {
              "id": "C",
              "text": "Option C: Discipline the nurse without reviewing the process does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Move only these two patients and close the review does not fit the decisive finding: wrong-patient alert before administration. Analyze near misses for latent system defects even when the safety barrier prevents harm."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i002-iron-deficiency-colon-evaluation",
      "expectedHashes": {
        "ranaze_step3_uat": "4b93c1fd9f1cc60686c1bb5b4d99fdac0164dace9266dd36140d61a4a8e643b2",
        "ranaze_step3_prd": "4b93c1fd9f1cc60686c1bb5b4d99fdac0164dace9266dd36140d61a4a8e643b2"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            },
            {
              "id": "C",
              "text": "Option D: Obtain a bone marrow biopsy is inappropriate because bone marrow biopsy is unnecessary when peripheral laboratory findings already establish iron deficiency and does not evaluate its likely source."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option D: Obtain a bone marrow biopsy is inappropriate because bone marrow biopsy is unnecessary when peripheral laboratory findings already establish iron deficiency and does not evaluate its likely source."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a bone marrow biopsy is inappropriate because bone marrow biopsy is unnecessary when peripheral laboratory findings already establish iron deficiency and does not evaluate its likely source."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a bone marrow biopsy is inappropriate because bone marrow biopsy is unnecessary when peripheral laboratory findings already establish iron deficiency and does not evaluate its likely source."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a contrast-enhanced CT scan of the abdomen is inappropriate because routine abdominal CT is less sensitive than colonoscopy for many mucosal lesions and does not permit immediate biopsy."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a contrast-enhanced CT scan of the abdomen is inappropriate because routine abdominal CT is less sensitive than colonoscopy for many mucosal lesions and does not permit immediate biopsy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a fecal immunochemical test and perform colonoscopy only if the result is positive is inappropriate because fIT is a colorectal cancer screening test for asymptomatic average-risk adults. This patient already has iron-deficiency anemia and new bowel symptoms, so a negative FIT would not safely eliminate the need for diagnostic endoscopy."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a fecal immunochemical test and perform colonoscopy only if the result is positive is inappropriate because fIT is a colorectal cancer screening test for asymptomatic average-risk adults. This patient already has iron-deficiency anemia and new bowel symptoms, so a negative FIT would not safely eliminate the need for diagnostic endoscopy."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform CT colonography is inappropriate because cT colonography can visualize the colon but cannot biopsy or remove a lesion; any abnormality requires subsequent colonoscopy. With iron-deficiency anemia and altered bowel habits, standard colonoscopy is the appropriate direct diagnostic procedure."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform CT colonography is inappropriate because cT colonography can visualize the colon but cannot biopsy or remove a lesion; any abnormality requires subsequent colonoscopy. With iron-deficiency anemia and altered bowel habits, standard colonoscopy is the appropriate direct diagnostic procedure."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform flexible sigmoidoscopy is inappropriate because flexible sigmoidoscopy examines only the rectum and distal colon. Iron-deficiency anemia in a postmenopausal adult requires evaluation for bleeding lesions throughout the colon."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform flexible sigmoidoscopy is inappropriate because flexible sigmoidoscopy examines only the rectum and distal colon. Iron-deficiency anemia in a postmenopausal adult requires evaluation for bleeding lesions throughout the colon."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform esophagogastroduodenoscopy without lower gastrointestinal evaluation is inappropriate because upper endoscopy may ultimately be included in bidirectional evaluation, but performing it without lower gastrointestinal evaluation inadequately addresses her new constipation and narrow stools, which specifically raise concern for colonic disease."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform esophagogastroduodenoscopy without lower gastrointestinal evaluation is inappropriate because upper endoscopy may ultimately be included in bidirectional evaluation, but performing it without lower gastrointestinal evaluation inadequately addresses her new constipation and narrow stools, which specifically raise concern for colonic disease."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform video capsule endoscopy is inappropriate because capsule endoscopy evaluates the small bowel and is generally reserved for selected patients after unrevealing initial upper and lower endoscopy. It is premature before colonoscopy."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform video capsule endoscopy is inappropriate because capsule endoscopy evaluates the small bowel and is generally reserved for selected patients after unrevealing initial upper and lower endoscopy. It is premature before colonoscopy."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure the serum carcinoembryonic antigen concentration is inappropriate because cEA has inadequate sensitivity and specificity for colorectal cancer screening or diagnosis. It is principally used after a diagnosis for prognostic or surveillance purposes and cannot replace colonoscopy with biopsy."
            },
            {
              "id": "B",
              "text": "Option A: Transfuse packed red blood cells is inappropriate because transfusion is generally reserved for hemodynamic instability, active major bleeding, severe symptoms, or substantially lower hemoglobin levels. This patient is stable."
            },
            {
              "id": "C",
              "text": "Option B: Begin oral iron and reassess in six months without further testing is inappropriate because iron replacement is appropriate but should not be the only intervention because an occult gastrointestinal source must be investigated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure the serum carcinoembryonic antigen concentration is inappropriate because cEA has inadequate sensitivity and specificity for colorectal cancer screening or diagnosis. It is principally used after a diagnosis for prognostic or surveillance purposes and cannot replace colonoscopy with biopsy."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i003-noncomparative-case-series",
      "expectedHashes": {
        "ranaze_step3_uat": "9b69be5e31a53e1b100500c99f73571ddb28ff8ced731208f54087da31972beb",
        "ranaze_step3_prd": "9b69be5e31a53e1b100500c99f73571ddb28ff8ced731208f54087da31972beb"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "B",
              "text": "Option B: Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            },
            {
              "id": "C",
              "text": "Option C: Both treatments should be combined because neither report showed universal survival is inappropriate because separate case series provide no evidence that combining both treatments improves survival and may expose patients to additional adverse effects."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            },
            {
              "id": "B",
              "text": "Option A: Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "C",
              "text": "Option C: Both treatments should be combined because neither report showed universal survival is inappropriate because separate case series provide no evidence that combining both treatments improves survival and may expose patients to additional adverse effects."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Both treatments should be combined because neither report showed universal survival is inappropriate because separate case series provide no evidence that combining both treatments improves survival and may expose patients to additional adverse effects."
            },
            {
              "id": "B",
              "text": "Option A: Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "C",
              "text": "Option B: Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Both treatments should be combined because neither report showed universal survival is inappropriate because separate case series provide no evidence that combining both treatments improves survival and may expose patients to additional adverse effects."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The treatment with the larger reported cohort should be considered more effective is inappropriate because a larger sample can improve precision within a study but cannot correct systematic differences between noncomparative cohorts."
            },
            {
              "id": "B",
              "text": "Option A: Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "C",
              "text": "Option B: Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The treatment with the larger reported cohort should be considered more effective is inappropriate because a larger sample can improve precision within a study but cannot correct systematic differences between noncomparative cohorts."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Test the difference between the two survival proportions and accept the superior treatment if the P value is significant is inappropriate because a significance test addresses sampling variability, not systematic bias. Even a very small P value cannot make nonconcurrent, noncomparable case series into a valid treatment comparison."
            },
            {
              "id": "B",
              "text": "Option A: Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "C",
              "text": "Option B: Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Test the difference between the two survival proportions and accept the superior treatment if the P value is significant is inappropriate because a significance test addresses sampling variability, not systematic bias. Even a very small P value cannot make nonconcurrent, noncomparable case series into a valid treatment comparison."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Meta-analyze the two case series to determine which treatment improves survival is inappropriate because meta-analysis cannot manufacture a valid comparative effect from one uncontrolled series per treatment. Weighting or pooling biased, heterogeneous cohorts does not correct the absence of comparable treatment groups."
            },
            {
              "id": "B",
              "text": "Option A: Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "C",
              "text": "Option B: Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Meta-analyze the two case series to determine which treatment improves survival is inappropriate because meta-analysis cannot manufacture a valid comparative effect from one uncontrolled series per treatment. Weighting or pooling biased, heterogeneous cohorts does not correct the absence of comparable treatment groups."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Compare survival after stratifying only by the incompletely reported tumor risk groups is inappropriate because adequate adjustment requires consistently measured prognostic variables. The reports provide incomplete tumor-risk information and used different eligibility criteria, so partial stratification cannot establish exchangeable groups."
            },
            {
              "id": "B",
              "text": "Option A: Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "C",
              "text": "Option B: Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Compare survival after stratifying only by the incompletely reported tumor risk groups is inappropriate because adequate adjustment requires consistently measured prognostic variables. The reports provide incomplete tumor-risk information and used different eligibility criteria, so partial stratification cannot establish exchangeable groups."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Compare each cohort with a historical untreated prostate cancer population to establish treatment efficacy is inappropriate because historical controls remain vulnerable to differences in patient selection, staging, supportive care, calendar time, and outcome ascertainment. They would not provide the concurrent comparable groups needed for a reliable relative-effect estimate."
            },
            {
              "id": "B",
              "text": "Option A: Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "C",
              "text": "Option B: Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Compare each cohort with a historical untreated prostate cancer population to establish treatment efficacy is inappropriate because historical controls remain vulnerable to differences in patient selection, staging, supportive care, calendar time, and outcome ascertainment. They would not provide the concurrent comparable groups needed for a reliable relative-effect estimate."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Calculate a number needed to treat from the 12-percentage-point survival difference is inappropriate because number needed to treat requires a credible causal absolute risk difference. The observed 12-point difference between unrelated case series cannot be interpreted as an attributable treatment effect."
            },
            {
              "id": "B",
              "text": "Option A: Surgery should be recommended because its reported survival was higher is inappropriate because the higher observed survival after surgery may reflect patient selection or baseline prognostic differences rather than a treatment effect."
            },
            {
              "id": "C",
              "text": "Option B: Radiation should be recommended because its cohort was treated in the community is inappropriate because the community setting does not establish greater effectiveness, and the radiation cohort cannot be directly compared with the surgical cohort."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Calculate a number needed to treat from the 12-percentage-point survival difference is inappropriate because number needed to treat requires a credible causal absolute risk difference. The observed 12-point difference between unrelated case series cannot be interpreted as an attributable treatment effect."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i004-osteoporotic-vertebral-compression-fracture",
      "expectedHashes": {
        "ranaze_step3_uat": "eb2252cedc61547a32b690e58f3b9944f4263f6321cac1d9f6e0324675d5a8c4",
        "ranaze_step3_prd": "eb2252cedc61547a32b690e58f3b9944f4263f6321cac1d9f6e0324675d5a8c4"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "B",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            },
            {
              "id": "C",
              "text": "Option D: Mechanical paraspinal muscle strain is inappropriate because muscle strain may follow lifting but more often causes paraspinal tenderness or spasm rather than focal tenderness directly over a vertebra and progressive height loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option D: Mechanical paraspinal muscle strain is inappropriate because muscle strain may follow lifting but more often causes paraspinal tenderness or spasm rather than focal tenderness directly over a vertebra and progressive height loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mechanical paraspinal muscle strain is inappropriate because muscle strain may follow lifting but more often causes paraspinal tenderness or spasm rather than focal tenderness directly over a vertebra and progressive height loss."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mechanical paraspinal muscle strain is inappropriate because muscle strain may follow lifting but more often causes paraspinal tenderness or spasm rather than focal tenderness directly over a vertebra and progressive height loss."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vertebral osteomyelitis generally causes persistent pain and is associated with risk factors or systemic evidence of infection, which are not described."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vertebral osteomyelitis generally causes persistent pain and is associated with risk factors or systemic evidence of infection, which are not described."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vertebral metastasis causing a pathologic fracture is inappropriate because malignancy can cause a pathologic vertebral fracture, but this patient has a strong osteoporosis mechanism: advanced age, four years of prednisone exposure, progressive height loss, and sudden pain after minimal loading. No cancer history or other malignancy feature is provided."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vertebral metastasis causing a pathologic fracture is inappropriate because malignancy can cause a pathologic vertebral fracture, but this patient has a strong osteoporosis mechanism: advanced age, four years of prednisone exposure, progressive height loss, and sudden pain after minimal loading. No cancer history or other malignancy feature is provided."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Multiple myeloma with a pathologic vertebral fracture is inappropriate because myeloma may produce vertebral collapse, but the stem provides no systemic, hematologic, renal, or multifocal bone findings. The explicit glucocorticoid exposure and fragility mechanism much more specifically indicate osteoporotic compression fracture."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Multiple myeloma with a pathologic vertebral fracture is inappropriate because myeloma may produce vertebral collapse, but the stem provides no systemic, hematologic, renal, or multifocal bone findings. The explicit glucocorticoid exposure and fragility mechanism much more specifically indicate osteoporotic compression fracture."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cauda equina syndrome causes compression of lumbosacral nerve roots with neurologic deficits, often including weakness, sensory loss, reflex changes, or bladder and bowel dysfunction. Her lower-extremity neurologic examination is normal."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cauda equina syndrome causes compression of lumbosacral nerve roots with neurologic deficits, often including weakness, sensory loss, reflex changes, or bladder and bowel dysfunction. Her lower-extremity neurologic examination is normal."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Spinal epidural abscess usually produces persistent spinal pain and may progress to fever or neurologic compromise. The abrupt onset during lifting, positional improvement, height loss, and focal L1 tenderness are more characteristic of a fragility fracture."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Spinal epidural abscess usually produces persistent spinal pain and may progress to fever or neurologic compromise. The abrupt onset during lifting, positional improvement, height loss, and focal L1 tenderness are more characteristic of a fragility fracture."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Degenerative lumbar spondylolisthesis is inappropriate because degenerative spondylolisthesis generally develops over time and may cause chronic mechanical pain, stenosis, or radicular symptoms. It is a poor fit for abrupt focal pain after minimal loading in a glucocorticoid-exposed patient."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Degenerative lumbar spondylolisthesis is inappropriate because degenerative spondylolisthesis generally develops over time and may cause chronic mechanical pain, stenosis, or radicular symptoms. It is a poor fit for abrupt focal pain after minimal loading in a glucocorticoid-exposed patient."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nephrolithiasis is inappropriate because renal colic commonly causes sharp flank pain that may radiate toward the abdomen or groin and can be accompanied by urinary findings, nausea, or vomiting. Focal midline L1 tenderness and movement-dependent pain favor a spinal lesion."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nephrolithiasis is inappropriate because renal colic commonly causes sharp flank pain that may radiate toward the abdomen or groin and can be accompanied by urinary findings, nausea, or vomiting. Focal midline L1 tenderness and movement-dependent pain favor a spinal lesion."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A ruptured abdominal aortic aneurysm causes sudden severe abdominal or back pain and physiologic instability rather than isolated movement-dependent pain with focal L1 tenderness. The examination also reports no abdominal tenderness."
            },
            {
              "id": "B",
              "text": "Option A: Lumbar spinal stenosis is inappropriate because spinal stenosis usually causes exertional leg discomfort or neurologic symptoms relieved by lumbar flexion rather than abrupt focal vertebral pain."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar disk herniation is inappropriate because disk herniation commonly produces radicular leg pain, sensory changes, weakness, or altered reflexes, none of which are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A ruptured abdominal aortic aneurysm causes sudden severe abdominal or back pain and physiologic instability rather than isolated movement-dependent pain with focal L1 tenderness. The examination also reports no abdominal tenderness."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i007-empathic-exploration",
      "expectedHashes": {
        "ranaze_step3_uat": "f8eee79922a2802f51c4f1c793fec736a3f2554483f54f0fbde90a9e849e39d1",
        "ranaze_step3_prd": "f8eee79922a2802f51c4f1c793fec736a3f2554483f54f0fbde90a9e849e39d1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u201CCarrier states are common, so neither you nor your son should be concerned.\u201D is inappropriate because this response minimizes the mother\u0027s expressed distress and closes further discussion."
            },
            {
              "id": "B",
              "text": "Option B: \u201CI can explain recessive inheritance to your son and ask whether he wants testing today.\u201D is inappropriate because the child has not participated in the discussion, and immediate testing should not be proposed before the mother\u0027s concerns and the lack of childhood medical benefit are addressed."
            },
            {
              "id": "C",
              "text": "Option C: \u201CI will give you written information about the disorder before we discuss this further.\u201D is inappropriate because written material may be useful later but does not directly respond to the mother\u0027s emotional statement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u201CCarrier states are common, so neither you nor your son should be concerned.\u201D is inappropriate because this response minimizes the mother\u0027s expressed distress and closes further discussion."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u201CI can explain recessive inheritance to your son and ask whether he wants testing today.\u201D is inappropriate because the child has not participated in the discussion, and immediate testing should not be proposed before the mother\u0027s concerns and the lack of childhood medical benefit are addressed."
            },
            {
              "id": "B",
              "text": "Option A: \u201CCarrier states are common, so neither you nor your son should be concerned.\u201D is inappropriate because this response minimizes the mother\u0027s expressed distress and closes further discussion."
            },
            {
              "id": "C",
              "text": "Option C: \u201CI will give you written information about the disorder before we discuss this further.\u201D is inappropriate because written material may be useful later but does not directly respond to the mother\u0027s emotional statement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u201CI can explain recessive inheritance to your son and ask whether he wants testing today.\u201D is inappropriate because the child has not participated in the discussion, and immediate testing should not be proposed before the mother\u0027s concerns and the lack of childhood medical benefit are addressed."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u201CI will give you written information about the disorder before we discuss this further.\u201D is inappropriate because written material may be useful later but does not directly respond to the mother\u0027s emotional statement."
            },
            {
              "id": "B",
              "text": "Option A: \u201CCarrier states are common, so neither you nor your son should be concerned.\u201D is inappropriate because this response minimizes the mother\u0027s expressed distress and closes further discussion."
            },
            {
              "id": "C",
              "text": "Option B: \u201CI can explain recessive inheritance to your son and ask whether he wants testing today.\u201D is inappropriate because the child has not participated in the discussion, and immediate testing should not be proposed before the mother\u0027s concerns and the lack of childhood medical benefit are addressed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u201CI will give you written information about the disorder before we discuss this further.\u201D is inappropriate because written material may be useful later but does not directly respond to the mother\u0027s emotional statement."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u201CTesting is available, and knowing his status now would eliminate uncertainty.\u201D is inappropriate because this prematurely endorses testing and overlooks the mother\u0027s emotional concerns as well as the child\u0027s future autonomy."
            },
            {
              "id": "B",
              "text": "Option A: \u201CCarrier states are common, so neither you nor your son should be concerned.\u201D is inappropriate because this response minimizes the mother\u0027s expressed distress and closes further discussion."
            },
            {
              "id": "C",
              "text": "Option B: \u201CI can explain recessive inheritance to your son and ask whether he wants testing today.\u201D is inappropriate because the child has not participated in the discussion, and immediate testing should not be proposed before the mother\u0027s concerns and the lack of childhood medical benefit are addressed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u201CTesting is available, and knowing his status now would eliminate uncertainty.\u201D is inappropriate because this prematurely endorses testing and overlooks the mother\u0027s emotional concerns as well as the child\u0027s future autonomy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u201CBecause carrier testing has no medical benefit during childhood, we should wait until your son is an adult to discuss it.\u201D is inappropriate because deferring routine childhood carrier testing is generally appropriate, but this response immediately announces a decision and bypasses the mother\u0027s explicit emotional cue. At this point, the physician should first explore what her result means to her."
            },
            {
              "id": "B",
              "text": "Option A: \u201CCarrier states are common, so neither you nor your son should be concerned.\u201D is inappropriate because this response minimizes the mother\u0027s expressed distress and closes further discussion."
            },
            {
              "id": "C",
              "text": "Option B: \u201CI can explain recessive inheritance to your son and ask whether he wants testing today.\u201D is inappropriate because the child has not participated in the discussion, and immediate testing should not be proposed before the mother\u0027s concerns and the lack of childhood medical benefit are addressed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u201CBecause carrier testing has no medical benefit during childhood, we should wait until your son is an adult to discuss it.\u201D is inappropriate because deferring routine childhood carrier testing is generally appropriate, but this response immediately announces a decision and bypasses the mother\u0027s explicit emotional cue. At this point, the physician should first explore what her result means to her."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u201CBecause his father tested negative, your son cannot be a carrier.\u201D is inappropriate because a child can inherit the mother\u0027s pathogenic allele and be a carrier even if the father does not carry it. A negative paternal result markedly reduces the risk of an affected child but does not eliminate maternal transmission."
            },
            {
              "id": "B",
              "text": "Option A: \u201CCarrier states are common, so neither you nor your son should be concerned.\u201D is inappropriate because this response minimizes the mother\u0027s expressed distress and closes further discussion."
            },
            {
              "id": "C",
              "text": "Option B: \u201CI can explain recessive inheritance to your son and ask whether he wants testing today.\u201D is inappropriate because the child has not participated in the discussion, and immediate testing should not be proposed before the mother\u0027s concerns and the lack of childhood medical benefit are addressed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u201CBecause his father tested negative, your son cannot be a carrier.\u201D is inappropriate because a child can inherit the mother\u0027s pathogenic allele and be a carrier even if the father does not carry it. A negative paternal result markedly reduces the risk of an affected child but does not eliminate maternal transmission."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i009-primary-hyperparathyroidism-nephrolithiasis",
      "expectedHashes": {
        "ranaze_step3_uat": "554e39bd29032908ea04d741d276dcaca4a51bcddea45df1d7a7d0e3182176f2",
        "ranaze_step3_prd": "554e39bd29032908ea04d741d276dcaca4a51bcddea45df1d7a7d0e3182176f2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "B",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            },
            {
              "id": "C",
              "text": "Option D: Measurement of fasting serum gastrin is inappropriate because gastrin measurement is used when a gastrinoma is suspected and does not explain this presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option D: Measurement of fasting serum gastrin is inappropriate because gastrin measurement is used when a gastrinoma is suspected and does not explain this presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measurement of fasting serum gastrin is inappropriate because gastrin measurement is used when a gastrinoma is suspected and does not explain this presentation."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measurement of fasting serum gastrin is inappropriate because gastrin measurement is used when a gastrinoma is suspected and does not explain this presentation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Quantification of protein excretion in a 24-hour urine collection is inappropriate because twenty-four-hour urine protein is used to quantify proteinuria, not to determine the cause of hypercalcemia and recurrent stones."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Quantification of protein excretion in a 24-hour urine collection is inappropriate because twenty-four-hour urine protein is used to quantify proteinuria, not to determine the cause of hypercalcemia and recurrent stones."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Comprehensive metabolic testing with two 24-hour urine collections is inappropriate because a 24-hour urine stone-risk profile is appropriate during the broader metabolic evaluation of recurrent stone formers, but the immediately displayed hypercalcemia and low phosphorus specifically require intact PTH measurement first to identify or exclude primary hyperparathyroidism."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Comprehensive metabolic testing with two 24-hour urine collections is inappropriate because a 24-hour urine stone-risk profile is appropriate during the broader metabolic evaluation of recurrent stone formers, but the immediately displayed hypercalcemia and low phosphorus specifically require intact PTH measurement first to identify or exclude primary hyperparathyroidism."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measurement of serum parathyroid hormone-related peptide is inappropriate because pTH-related peptide is evaluated after finding PTH-independent hypercalcemia, particularly when humoral malignancy is suspected. Endogenous intact PTH must first be measured to classify the hypercalcemia as PTH-dependent or PTH-independent."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measurement of serum parathyroid hormone-related peptide is inappropriate because pTH-related peptide is evaluated after finding PTH-independent hypercalcemia, particularly when humoral malignancy is suspected. Endogenous intact PTH must first be measured to classify the hypercalcemia as PTH-dependent or PTH-independent."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measurement of serum 25-hydroxyvitamin D is inappropriate because vitamin D status is part of the subsequent evaluation of confirmed or suspected primary hyperparathyroidism, but 25-hydroxyvitamin D alone does not establish whether the elevated calcium is PTH-mediated. Intact PTH is the priority test."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measurement of serum 25-hydroxyvitamin D is inappropriate because vitamin D status is part of the subsequent evaluation of confirmed or suspected primary hyperparathyroidism, but 25-hydroxyvitamin D alone does not establish whether the elevated calcium is PTH-mediated. Intact PTH is the priority test."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Technetium-99m sestamibi parathyroid scintigraphy is inappropriate because sestamibi scanning localizes abnormal parathyroid tissue for operative planning; it does not establish the biochemical diagnosis. PTH should be measured before localization imaging."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Technetium-99m sestamibi parathyroid scintigraphy is inappropriate because sestamibi scanning localizes abnormal parathyroid tissue for operative planning; it does not establish the biochemical diagnosis. PTH should be measured before localization imaging."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measurement of the urinary calcium-to-creatinine clearance ratio is inappropriate because the urinary calcium-to-creatinine clearance ratio helps distinguish familial hypocalciuric hypercalcemia from primary hyperparathyroidism after PTH-dependent hypercalcemia has been demonstrated. It does not replace the initial intact PTH measurement."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measurement of the urinary calcium-to-creatinine clearance ratio is inappropriate because the urinary calcium-to-creatinine clearance ratio helps distinguish familial hypocalciuric hypercalcemia from primary hyperparathyroidism after PTH-dependent hypercalcemia has been demonstrated. It does not replace the initial intact PTH measurement."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measurement of serum 1,25-dihydroxyvitamin D is inappropriate because an elevated 1,25-dihydroxyvitamin D concentration may support granulomatous disease or lymphoma after suppressed PTH identifies PTH-independent hypercalcemia. It is not the initial test in this classic hypercalcemic stone presentation."
            },
            {
              "id": "B",
              "text": "Option B: Serum protein electrophoresis is inappropriate because protein electrophoresis can evaluate a monoclonal gammopathy, but the patient\u0027s age, normal hemoglobin, and normal renal function make this a less likely explanation."
            },
            {
              "id": "C",
              "text": "Option C: Urine culture is not the appropriate etiologic study when urinalysis shows hematuria without pyuria, nitrites, or leukocyte esterase."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measurement of serum 1,25-dihydroxyvitamin D is inappropriate because an elevated 1,25-dihydroxyvitamin D concentration may support granulomatous disease or lymphoma after suppressed PTH identifies PTH-independent hypercalcemia. It is not the initial test in this classic hypercalcemic stone presentation."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i014-confidence-interval-interpretation",
      "expectedHashes": {
        "ranaze_step3_uat": "f347b8b25bc87a52fd895387c5e459efcb70dfb78836c0b1e814ad6a0088812c",
        "ranaze_step3_prd": "f347b8b25bc87a52fd895387c5e459efcb70dfb78836c0b1e814ad6a0088812c"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "B",
              "text": "Option B: Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            },
            {
              "id": "C",
              "text": "Option D: The probability that active cancer is unrelated to pulmonary embolism is 5% is inappropriate because a confidence interval does not state the probability that the null hypothesis is true."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            },
            {
              "id": "B",
              "text": "Option A: There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "C",
              "text": "Option D: The probability that active cancer is unrelated to pulmonary embolism is 5% is inappropriate because a confidence interval does not state the probability that the null hypothesis is true."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The probability that active cancer is unrelated to pulmonary embolism is 5% is inappropriate because a confidence interval does not state the probability that the null hypothesis is true."
            },
            {
              "id": "B",
              "text": "Option A: There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "C",
              "text": "Option B: Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The probability that active cancer is unrelated to pulmonary embolism is 5% is inappropriate because a confidence interval does not state the probability that the null hypothesis is true."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Five percent of repeated studies would produce an odds ratio below 1.4 is inappropriate because the excluded intervals are split across both tails and concern whether intervals contain the true parameter, not whether point estimates fall below one endpoint."
            },
            {
              "id": "B",
              "text": "Option A: There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "C",
              "text": "Option B: Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Five percent of repeated studies would produce an odds ratio below 1.4 is inappropriate because the excluded intervals are split across both tails and concern whether intervals contain the true parameter, not whether point estimates fall below one endpoint."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Between 1.4% and 4.8% of patients with postoperative pulmonary embolism have active cancer is inappropriate because an odds ratio compares exposure odds between cases and controls; neither the odds ratio nor its confidence limits state the prevalence of active cancer among patients with pulmonary embolism."
            },
            {
              "id": "B",
              "text": "Option A: There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "C",
              "text": "Option B: Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Between 1.4% and 4.8% of patients with postoperative pulmonary embolism have active cancer is inappropriate because an odds ratio compares exposure odds between cases and controls; neither the odds ratio nor its confidence limits state the prevalence of active cancer among patients with pulmonary embolism."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Active cancer increases the absolute risk of postoperative pulmonary embolism by 1.4 to 4.8 percentage points is inappropriate because the reported measure is an odds ratio, a relative measure of association. Absolute risk differences cannot be recovered from this interval and generally are not directly estimated by a case-control study."
            },
            {
              "id": "B",
              "text": "Option A: There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "C",
              "text": "Option B: Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Active cancer increases the absolute risk of postoperative pulmonary embolism by 1.4 to 4.8 percentage points is inappropriate because the reported measure is an odds ratio, a relative measure of association. Absolute risk differences cannot be recovered from this interval and generally are not directly estimated by a case-control study."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Every odds ratio between 1.4 and 4.8 is equally likely to be the true population odds ratio is inappropriate because a frequentist confidence interval supplies no probability distribution over parameter values. It therefore does not imply that values within the interval are equally likely."
            },
            {
              "id": "B",
              "text": "Option A: There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "C",
              "text": "Option B: Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Every odds ratio between 1.4 and 4.8 is equally likely to be the true population odds ratio is inappropriate because a frequentist confidence interval supplies no probability distribution over parameter values. It therefore does not imply that values within the interval are equally likely."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "There is a 95% probability that active cancer causes postoperative pulmonary embolism is inappropriate because exclusion of the null value supports a statistically significant association, but a case-control study and its confidence interval do not by themselves establish causation or assign causation a probability."
            },
            {
              "id": "B",
              "text": "Option A: There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "C",
              "text": "Option B: Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "There is a 95% probability that active cancer causes postoperative pulmonary embolism is inappropriate because exclusion of the null value supports a statistically significant association, but a case-control study and its confidence interval do not by themselves establish causation or assign causation a probability."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "There is a 5% probability that the true population odds ratio lies outside 1.4 to 4.8 is inappropriate because after a frequentist interval has been calculated, the parameter is fixed and the interval either covers it or does not. The 5% noncoverage rate applies to the interval-generating procedure over repeated sampling, not as a posterior probability for this particular parameter."
            },
            {
              "id": "B",
              "text": "Option A: There is a 95% probability that this study\u0027s observed odds ratio lies between 1.4 and 4.8 is inappropriate because once an interval has been calculated, the observed estimate and its endpoints are fixed; frequentist analysis does not assign a 95% probability to this particular interval containing the parameter."
            },
            {
              "id": "C",
              "text": "Option B: Ninety-five percent of patients with active cancer have an odds ratio between 1.4 and 4.8 is inappropriate because a confidence interval describes uncertainty in a population effect estimate, not the distribution of individual patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "There is a 5% probability that the true population odds ratio lies outside 1.4 to 4.8 is inappropriate because after a frequentist interval has been calculated, the parameter is fixed and the interval either covers it or does not. The 5% noncoverage rate applies to the interval-generating procedure over repeated sampling, not as a posterior probability for this particular parameter."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i016-ischemic-colitis",
      "expectedHashes": {
        "ranaze_step3_uat": "7ab18b1c846d1dc5fe1b4854b4d3252fd571dd9172cc179c6e1c7d1f493db054",
        "ranaze_step3_prd": "7ab18b1c846d1dc5fe1b4854b4d3252fd571dd9172cc179c6e1c7d1f493db054"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute mesenteric ischemia from superior mesenteric artery embolism is inappropriate because acute superior mesenteric artery occlusion usually causes severe, diffuse pain out of proportion to the initial examination and most often affects the small bowel or right colon."
            },
            {
              "id": "B",
              "text": "Option C: Ulcerative colitis usually causes a recurrent or persistent inflammatory diarrheal illness rather than an abrupt event associated with hypotension."
            },
            {
              "id": "C",
              "text": "Option D: Left-sided colorectal carcinoma is inappropriate because colorectal cancer may cause bleeding or altered bowel habits but is unlikely to produce this sudden sequence of pain and bloody diarrhea."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute mesenteric ischemia from superior mesenteric artery embolism is inappropriate because acute superior mesenteric artery occlusion usually causes severe, diffuse pain out of proportion to the initial examination and most often affects the small bowel or right colon."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ulcerative colitis usually causes a recurrent or persistent inflammatory diarrheal illness rather than an abrupt event associated with hypotension."
            },
            {
              "id": "B",
              "text": "Option A: Acute mesenteric ischemia from superior mesenteric artery embolism is inappropriate because acute superior mesenteric artery occlusion usually causes severe, diffuse pain out of proportion to the initial examination and most often affects the small bowel or right colon."
            },
            {
              "id": "C",
              "text": "Option D: Left-sided colorectal carcinoma is inappropriate because colorectal cancer may cause bleeding or altered bowel habits but is unlikely to produce this sudden sequence of pain and bloody diarrhea."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ulcerative colitis usually causes a recurrent or persistent inflammatory diarrheal illness rather than an abrupt event associated with hypotension."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Left-sided colorectal carcinoma is inappropriate because colorectal cancer may cause bleeding or altered bowel habits but is unlikely to produce this sudden sequence of pain and bloody diarrhea."
            },
            {
              "id": "B",
              "text": "Option A: Acute mesenteric ischemia from superior mesenteric artery embolism is inappropriate because acute superior mesenteric artery occlusion usually causes severe, diffuse pain out of proportion to the initial examination and most often affects the small bowel or right colon."
            },
            {
              "id": "C",
              "text": "Option C: Ulcerative colitis usually causes a recurrent or persistent inflammatory diarrheal illness rather than an abrupt event associated with hypotension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Left-sided colorectal carcinoma is inappropriate because colorectal cancer may cause bleeding or altered bowel habits but is unlikely to produce this sudden sequence of pain and bloody diarrhea."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute diverticulitis is inappropriate because diverticulitis causes focal pain and fever; significant hematochezia is more typical of diverticulosis and is usually painless."
            },
            {
              "id": "B",
              "text": "Option A: Acute mesenteric ischemia from superior mesenteric artery embolism is inappropriate because acute superior mesenteric artery occlusion usually causes severe, diffuse pain out of proportion to the initial examination and most often affects the small bowel or right colon."
            },
            {
              "id": "C",
              "text": "Option C: Ulcerative colitis usually causes a recurrent or persistent inflammatory diarrheal illness rather than an abrupt event associated with hypotension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute diverticulitis is inappropriate because diverticulitis causes focal pain and fever; significant hematochezia is more typical of diverticulosis and is usually painless."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute diverticular hemorrhage is inappropriate because diverticular hemorrhage commonly causes sudden, substantial, painless hematochezia. It does not fit the characteristic sequence of abrupt cramping pain followed hours later by bloody diarrhea during hypotension."
            },
            {
              "id": "B",
              "text": "Option A: Acute mesenteric ischemia from superior mesenteric artery embolism is inappropriate because acute superior mesenteric artery occlusion usually causes severe, diffuse pain out of proportion to the initial examination and most often affects the small bowel or right colon."
            },
            {
              "id": "C",
              "text": "Option C: Ulcerative colitis usually causes a recurrent or persistent inflammatory diarrheal illness rather than an abrupt event associated with hypotension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute diverticular hemorrhage is inappropriate because diverticular hemorrhage commonly causes sudden, substantial, painless hematochezia. It does not fit the characteristic sequence of abrupt cramping pain followed hours later by bloody diarrhea during hypotension."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Colonic angiodysplasia is inappropriate because angiodysplasia can cause lower gastrointestinal bleeding in older adults, but bleeding is generally painless and is not linked to an acute low-flow episode or cramping left-sided pain."
            },
            {
              "id": "B",
              "text": "Option A: Acute mesenteric ischemia from superior mesenteric artery embolism is inappropriate because acute superior mesenteric artery occlusion usually causes severe, diffuse pain out of proportion to the initial examination and most often affects the small bowel or right colon."
            },
            {
              "id": "C",
              "text": "Option C: Ulcerative colitis usually causes a recurrent or persistent inflammatory diarrheal illness rather than an abrupt event associated with hypotension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Colonic angiodysplasia is inappropriate because angiodysplasia can cause lower gastrointestinal bleeding in older adults, but bleeding is generally painless and is not linked to an acute low-flow episode or cramping left-sided pain."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Brisk upper gastrointestinal bleeding from a peptic ulcer is inappropriate because a very brisk upper gastrointestinal bleed can present as hematochezia, especially with instability, but this patient has focal left-sided cramping followed by blood mixed with loose stool and no upper gastrointestinal symptoms."
            },
            {
              "id": "B",
              "text": "Option A: Acute mesenteric ischemia from superior mesenteric artery embolism is inappropriate because acute superior mesenteric artery occlusion usually causes severe, diffuse pain out of proportion to the initial examination and most often affects the small bowel or right colon."
            },
            {
              "id": "C",
              "text": "Option C: Ulcerative colitis usually causes a recurrent or persistent inflammatory diarrheal illness rather than an abrupt event associated with hypotension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Brisk upper gastrointestinal bleeding from a peptic ulcer is inappropriate because a very brisk upper gastrointestinal bleed can present as hematochezia, especially with instability, but this patient has focal left-sided cramping followed by blood mixed with loose stool and no upper gastrointestinal symptoms."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i017-diabetic-foot-inspection",
      "expectedHashes": {
        "ranaze_step3_uat": "6ded6d224f2eb0c8db71b248ff1f858e7dfbe6086e9acffba4af8396f2dd1159",
        "ranaze_step3_prd": "6ded6d224f2eb0c8db71b248ff1f858e7dfbe6086e9acffba4af8396f2dd1159"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Palpation of the epitrochlear lymph nodes is inappropriate because epitrochlear lymph-node examination is not a priority based on the findings presented."
            },
            {
              "id": "B",
              "text": "Option B: Assessment of extraocular muscle function is inappropriate because diabetes warrants periodic retinal evaluation, but extraocular muscle testing does not address her immediate risk from peripheral sensory loss."
            },
            {
              "id": "C",
              "text": "Option C: Examination of the proximal interphalangeal joints is inappropriate because examination of the hand joints would not evaluate complications suggested by absent plantar sensation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Palpation of the epitrochlear lymph nodes is inappropriate because epitrochlear lymph-node examination is not a priority based on the findings presented."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Assessment of extraocular muscle function is inappropriate because diabetes warrants periodic retinal evaluation, but extraocular muscle testing does not address her immediate risk from peripheral sensory loss."
            },
            {
              "id": "B",
              "text": "Option A: Palpation of the epitrochlear lymph nodes is inappropriate because epitrochlear lymph-node examination is not a priority based on the findings presented."
            },
            {
              "id": "C",
              "text": "Option C: Examination of the proximal interphalangeal joints is inappropriate because examination of the hand joints would not evaluate complications suggested by absent plantar sensation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Assessment of extraocular muscle function is inappropriate because diabetes warrants periodic retinal evaluation, but extraocular muscle testing does not address her immediate risk from peripheral sensory loss."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Examination of the proximal interphalangeal joints is inappropriate because examination of the hand joints would not evaluate complications suggested by absent plantar sensation."
            },
            {
              "id": "B",
              "text": "Option A: Palpation of the epitrochlear lymph nodes is inappropriate because epitrochlear lymph-node examination is not a priority based on the findings presented."
            },
            {
              "id": "C",
              "text": "Option B: Assessment of extraocular muscle function is inappropriate because diabetes warrants periodic retinal evaluation, but extraocular muscle testing does not address her immediate risk from peripheral sensory loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Examination of the proximal interphalangeal joints is inappropriate because examination of the hand joints would not evaluate complications suggested by absent plantar sensation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Testing of the gag reflex is inappropriate because gag-reflex testing is not indicated without symptoms or findings suggesting bulbar dysfunction."
            },
            {
              "id": "B",
              "text": "Option A: Palpation of the epitrochlear lymph nodes is inappropriate because epitrochlear lymph-node examination is not a priority based on the findings presented."
            },
            {
              "id": "C",
              "text": "Option B: Assessment of extraocular muscle function is inappropriate because diabetes warrants periodic retinal evaluation, but extraocular muscle testing does not address her immediate risk from peripheral sensory loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Testing of the gag reflex is inappropriate because gag-reflex testing is not indicated without symptoms or findings suggesting bulbar dysfunction."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dilated funduscopic examination is inappropriate because diabetes warrants retinal screening, generally through a dilated eye examination or validated retinal imaging, but fundoscopy does not address the immediate hazard established by her loss of protective plantar sensation. Detailed inspection of the feet is the priority."
            },
            {
              "id": "B",
              "text": "Option A: Palpation of the epitrochlear lymph nodes is inappropriate because epitrochlear lymph-node examination is not a priority based on the findings presented."
            },
            {
              "id": "C",
              "text": "Option B: Assessment of extraocular muscle function is inappropriate because diabetes warrants periodic retinal evaluation, but extraocular muscle testing does not address her immediate risk from peripheral sensory loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dilated funduscopic examination is inappropriate because diabetes warrants retinal screening, generally through a dilated eye examination or validated retinal imaging, but fundoscopy does not address the immediate hazard established by her loss of protective plantar sensation. Detailed inspection of the feet is the priority."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measurement of supine and standing blood pressure is inappropriate because orthostatic measurements can evaluate suspected autonomic dysfunction, but no postural symptom is presented. The demonstrated problem is loss of protective sensation in the feet."
            },
            {
              "id": "B",
              "text": "Option A: Palpation of the epitrochlear lymph nodes is inappropriate because epitrochlear lymph-node examination is not a priority based on the findings presented."
            },
            {
              "id": "C",
              "text": "Option B: Assessment of extraocular muscle function is inappropriate because diabetes warrants periodic retinal evaluation, but extraocular muscle testing does not address her immediate risk from peripheral sensory loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measurement of supine and standing blood pressure is inappropriate because orthostatic measurements can evaluate suspected autonomic dysfunction, but no postural symptom is presented. The demonstrated problem is loss of protective sensation in the feet."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i018-orthostatic-z-score",
      "expectedHashes": {
        "ranaze_step3_uat": "315cdbb58d6675bc8370c3229ba0b066d50a06c4e103deedc42a810b5836d621",
        "ranaze_step3_prd": "315cdbb58d6675bc8370c3229ba0b066d50a06c4e103deedc42a810b5836d621"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "B",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            },
            {
              "id": "C",
              "text": "Option C: His systolic response is equal to the population mean. is inappropriate because the patient\u0027s systolic change is -29 mm Hg, whereas the study mean is -5 mm Hg."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option C: His systolic response is equal to the population mean. is inappropriate because the patient\u0027s systolic change is -29 mm Hg, whereas the study mean is -5 mm Hg."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His systolic response is equal to the population mean. is inappropriate because the patient\u0027s systolic change is -29 mm Hg, whereas the study mean is -5 mm Hg."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His systolic response is equal to the population mean. is inappropriate because the patient\u0027s systolic change is -29 mm Hg, whereas the study mean is -5 mm Hg."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Approximately one sixth of the study population would have a systolic decrease at least this large. is inappropriate because a one-in-six frequency corresponds roughly to a value one standard deviation beyond the mean, whereas this systolic change is two standard deviations beyond it."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Approximately one sixth of the study population would have a systolic decrease at least this large. is inappropriate because a one-in-six frequency corresponds roughly to a value one standard deviation beyond the mean, whereas this systolic change is two standard deviations beyond it."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His systolic response lies near the 98th percentile of the study distribution. is inappropriate because the systolic z score is (-29 - [-5])/12 = -2, so the response is near the 2nd percentile, not the 98th percentile. The sign of the z score determines which tail contains the observation."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His systolic response lies near the 98th percentile of the study distribution. is inappropriate because the systolic z score is (-29 - [-5])/12 = -2, so the response is near the 2nd percentile, not the 98th percentile. The sign of the z score determines which tail contains the observation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Both his systolic and diastolic changes are at least two standard deviations below their respective means. is inappropriate because the systolic z score is -2.0, but the diastolic z score is (-16 - [-3])/10 = -1.3. The diastolic response is not two standard deviations below its mean."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Both his systolic and diastolic changes are at least two standard deviations below their respective means. is inappropriate because the systolic z score is -2.0, but the diastolic z score is (-16 - [-3])/10 = -1.3. The diastolic response is not two standard deviations below its mean."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His diastolic decrease is greater in magnitude than that of approximately 98% of the study population. is inappropriate because a diastolic z score of -1.3 is near the 10th percentile, so the decrease is greater than that of roughly 90% rather than 98% of the population."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His diastolic decrease is greater in magnitude than that of approximately 98% of the study population. is inappropriate because a diastolic z score of -1.3 is near the 10th percentile, so the decrease is greater than that of roughly 90% rather than 98% of the population."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His systolic z score is -2.4 because -29 divided by 12 equals approximately -2.4. is inappropriate because a z score must center the observation by subtracting the population mean before dividing by the standard deviation. The correct calculation is [-29 - (-5)]/12 = -2.0, not -29/12."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His systolic z score is -2.4 because -29 divided by 12 equals approximately -2.4. is inappropriate because a z score must center the observation by subtracting the population mean before dividing by the standard deviation. The correct calculation is [-29 - (-5)]/12 = -2.0, not -29/12."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His systolic z score is \u002B2 because the magnitude of the decrease is two standard deviations from the mean. is inappropriate because the patient\u0027s change is below the mean, so its z score is negative. Taking the absolute magnitude may describe extremeness, but it cannot reverse the percentile-tail direction."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His systolic z score is \u002B2 because the magnitude of the decrease is two standard deviations from the mean. is inappropriate because the patient\u0027s change is below the mean, so its z score is negative. Taking the absolute magnitude may describe extremeness, but it cannot reverse the percentile-tail direction."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Approximately 5% of the study population would have a systolic decrease at least this large. is inappropriate because about 5% lies outside \u00B11.96 standard deviations in both tails combined. The relevant probability is the single lower tail at z = -2, approximately 2.3%."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Approximately 5% of the study population would have a systolic decrease at least this large. is inappropriate because about 5% lies outside \u00B11.96 standard deviations in both tails combined. The relevant probability is the single lower tail at z = -2, approximately 2.3%."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His diastolic change is within one standard deviation of the study mean. is inappropriate because the diastolic change is 13 mm Hg below its mean, and the diastolic standard deviation is 10 mm Hg. Its z score is -1.3, placing it outside one standard deviation."
            },
            {
              "id": "B",
              "text": "Option A: Both pressure changes are within one standard deviation of their respective means. is inappropriate because the systolic change is two standard deviations below the study mean, not within one standard deviation."
            },
            {
              "id": "C",
              "text": "Option B: His diastolic response is more statistically unusual than his systolic response. is inappropriate because the systolic z score has the greater absolute value: 2.0 compared with 1.3 for the diastolic change."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His diastolic change is within one standard deviation of the study mean. is inappropriate because the diastolic change is 13 mm Hg below its mean, and the diastolic standard deviation is 10 mm Hg. Its z score is -1.3, placing it outside one standard deviation."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i021-private-safety-interview",
      "expectedHashes": {
        "ranaze_step3_uat": "f1fcacbc71f5144154a19e4bdf13fb19c0db5732c50c275d23341c2b08bffa70",
        "ranaze_step3_prd": "f1fcacbc71f5144154a19e4bdf13fb19c0db5732c50c275d23341c2b08bffa70"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "B",
              "text": "Option C: Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            },
            {
              "id": "C",
              "text": "Option D: Question the partner privately about the origin of the bruises is inappropriate because speaking only with the partner does not provide the patient a safe opportunity to describe her experience."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            },
            {
              "id": "B",
              "text": "Option B: Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "C",
              "text": "Option D: Question the partner privately about the origin of the bruises is inappropriate because speaking only with the partner does not provide the patient a safe opportunity to describe her experience."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Question the partner privately about the origin of the bruises is inappropriate because speaking only with the partner does not provide the patient a safe opportunity to describe her experience."
            },
            {
              "id": "B",
              "text": "Option B: Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "C",
              "text": "Option C: Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Question the partner privately about the origin of the bruises is inappropriate because speaking only with the partner does not provide the patient a safe opportunity to describe her experience."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediately report the partner to law enforcement is inappropriate because immediate police involvement is appropriate for imminent danger or certain reportable circumstances, but the clinician should first privately assess the patient and clarify the situation."
            },
            {
              "id": "B",
              "text": "Option B: Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "C",
              "text": "Option C: Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediately report the partner to law enforcement is inappropriate because immediate police involvement is appropriate for imminent danger or certain reportable circumstances, but the clinician should first privately assess the patient and clarify the situation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Interview the home health nurse before speaking with the patient alone is inappropriate because the nurse may later provide useful collateral information, but collateral history cannot replace giving the potentially mistreated patient an immediate private opportunity to disclose abuse, neglect, or coercion."
            },
            {
              "id": "B",
              "text": "Option B: Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "C",
              "text": "Option C: Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Interview the home health nurse before speaking with the patient alone is inappropriate because the nurse may later provide useful collateral information, but collateral history cannot replace giving the potentially mistreated patient an immediate private opportunity to disclose abuse, neglect, or coercion."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform formal decision-making-capacity testing before discussing safety is inappropriate because nothing in the stem establishes impaired decision-making capacity. The patient\u0027s monitoring of her partner suggests fear or coercion, so privacy is needed before deciding whether a formal capacity assessment is relevant."
            },
            {
              "id": "B",
              "text": "Option B: Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "C",
              "text": "Option C: Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform formal decision-making-capacity testing before discussing safety is inappropriate because nothing in the stem establishes impaired decision-making capacity. The patient\u0027s monitoring of her partner suggests fear or coercion, so privacy is needed before deciding whether a formal capacity assessment is relevant."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Confront the partner about the inconsistencies in the explanation is inappropriate because confronting a suspected perpetrator before privately assessing the patient can increase danger, provoke retaliation, and further suppress disclosure."
            },
            {
              "id": "B",
              "text": "Option B: Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "C",
              "text": "Option C: Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Confront the partner about the inconsistencies in the explanation is inappropriate because confronting a suspected perpetrator before privately assessing the patient can increase danger, provoke retaliation, and further suppress disclosure."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange immediate ambulance transfer to the emergency department is inappropriate because emergency transfer is warranted for acute medical instability or imminent danger. The available history is concerning but incomplete; the next step is to clarify immediate risk privately."
            },
            {
              "id": "B",
              "text": "Option B: Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "C",
              "text": "Option C: Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange immediate ambulance transfer to the emergency department is inappropriate because emergency transfer is warranted for acute medical instability or imminent danger. The available history is concerning but incomplete; the next step is to clarify immediate risk privately."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule a follow-up visit when the patient can arrange to be alone is inappropriate because deferring the assessment leaves a highly dependent patient in a potentially unsafe situation. Privacy should be created during the current encounter."
            },
            {
              "id": "B",
              "text": "Option B: Continue the interview with both individuals to obtain a balanced account is inappropriate because a joint discussion may inhibit disclosure because the patient depends on the partner and appears to monitor the partner\u0027s reaction."
            },
            {
              "id": "C",
              "text": "Option C: Begin an antidepressant and reassess her mood in several weeks is inappropriate because withdrawal can reflect depression, but possible mistreatment and immediate safety concerns must be assessed before symptoms are attributed to a primary mood disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule a follow-up visit when the patient can arrange to be alone is inappropriate because deferring the assessment leaves a highly dependent patient in a potentially unsafe situation. Privacy should be created during the current encounter."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i022-acute-psychosis-toxicology-screen",
      "expectedHashes": {
        "ranaze_step3_uat": "b5e7e27978d71c101c83a1b906f59aadb4c1ae9acdd6c60121160e1d16e416ac",
        "ranaze_step3_prd": "b5e7e27978d71c101c83a1b906f59aadb4c1ae9acdd6c60121160e1d16e416ac"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Porphobilinogen measurement is inappropriate because urine porphobilinogen is used when acute porphyria is suspected, typically with episodic abdominal pain, neuropathy, autonomic symptoms, or dark urine."
            },
            {
              "id": "B",
              "text": "Option C: Copper quantification is inappropriate because urinary copper studies may contribute to evaluation for Wilson disease, which more often produces hepatic disease, movement abnormalities, or a progressive psychiatric presentation."
            },
            {
              "id": "C",
              "text": "Option D: Bacterial culture is inappropriate because a urine culture evaluates urinary infection, for which this patient has no reported urinary symptoms or systemic infectious findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Porphobilinogen measurement is inappropriate because urine porphobilinogen is used when acute porphyria is suspected, typically with episodic abdominal pain, neuropathy, autonomic symptoms, or dark urine."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Copper quantification is inappropriate because urinary copper studies may contribute to evaluation for Wilson disease, which more often produces hepatic disease, movement abnormalities, or a progressive psychiatric presentation."
            },
            {
              "id": "B",
              "text": "Option B: Porphobilinogen measurement is inappropriate because urine porphobilinogen is used when acute porphyria is suspected, typically with episodic abdominal pain, neuropathy, autonomic symptoms, or dark urine."
            },
            {
              "id": "C",
              "text": "Option D: Bacterial culture is inappropriate because a urine culture evaluates urinary infection, for which this patient has no reported urinary symptoms or systemic infectious findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Copper quantification is inappropriate because urinary copper studies may contribute to evaluation for Wilson disease, which more often produces hepatic disease, movement abnormalities, or a progressive psychiatric presentation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bacterial culture is inappropriate because a urine culture evaluates urinary infection, for which this patient has no reported urinary symptoms or systemic infectious findings."
            },
            {
              "id": "B",
              "text": "Option B: Porphobilinogen measurement is inappropriate because urine porphobilinogen is used when acute porphyria is suspected, typically with episodic abdominal pain, neuropathy, autonomic symptoms, or dark urine."
            },
            {
              "id": "C",
              "text": "Option C: Copper quantification is inappropriate because urinary copper studies may contribute to evaluation for Wilson disease, which more often produces hepatic disease, movement abnormalities, or a progressive psychiatric presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bacterial culture is inappropriate because a urine culture evaluates urinary infection, for which this patient has no reported urinary symptoms or systemic infectious findings."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Heavy-metal analysis is inappropriate because targeted heavy-metal testing is guided by a credible exposure history and compatible gastrointestinal, hematologic, or neurologic findings."
            },
            {
              "id": "B",
              "text": "Option B: Porphobilinogen measurement is inappropriate because urine porphobilinogen is used when acute porphyria is suspected, typically with episodic abdominal pain, neuropathy, autonomic symptoms, or dark urine."
            },
            {
              "id": "C",
              "text": "Option C: Copper quantification is inappropriate because urinary copper studies may contribute to evaluation for Wilson disease, which more often produces hepatic disease, movement abnormalities, or a progressive psychiatric presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Heavy-metal analysis is inappropriate because targeted heavy-metal testing is guided by a credible exposure history and compatible gastrointestinal, hematologic, or neurologic findings."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A urine cannabinoid immunoassay alone is inappropriate because cannabis can precipitate psychosis, but a THC-only assay is unnecessarily narrow when the device\u0027s contents are unknown. A positive cannabinoid result also establishes prior exposure rather than proving current impairment."
            },
            {
              "id": "B",
              "text": "Option B: Porphobilinogen measurement is inappropriate because urine porphobilinogen is used when acute porphyria is suspected, typically with episodic abdominal pain, neuropathy, autonomic symptoms, or dark urine."
            },
            {
              "id": "C",
              "text": "Option C: Copper quantification is inappropriate because urinary copper studies may contribute to evaluation for Wilson disease, which more often produces hepatic disease, movement abnormalities, or a progressive psychiatric presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A urine cannabinoid immunoassay alone is inappropriate because cannabis can precipitate psychosis, but a THC-only assay is unnecessarily narrow when the device\u0027s contents are unknown. A positive cannabinoid result also establishes prior exposure rather than proving current impairment."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A urine amphetamine assay alone is inappropriate because stimulants could explain sleeplessness, agitation, tachycardia, and paranoia, but an amphetamine-only assay assumes the unidentified exposure. The initial test should screen across common drug classes."
            },
            {
              "id": "B",
              "text": "Option B: Porphobilinogen measurement is inappropriate because urine porphobilinogen is used when acute porphyria is suspected, typically with episodic abdominal pain, neuropathy, autonomic symptoms, or dark urine."
            },
            {
              "id": "C",
              "text": "Option C: Copper quantification is inappropriate because urinary copper studies may contribute to evaluation for Wilson disease, which more often produces hepatic disease, movement abnormalities, or a progressive psychiatric presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A urine amphetamine assay alone is inappropriate because stimulants could explain sleeplessness, agitation, tachycardia, and paranoia, but an amphetamine-only assay assumes the unidentified exposure. The initial test should screen across common drug classes."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A urine phencyclidine assay alone is inappropriate because phencyclidine can produce agitation and psychosis, but a PCP-only assay assumes a particular drug despite an unidentified device. A broad toxicology screen is the appropriate initial test."
            },
            {
              "id": "B",
              "text": "Option B: Porphobilinogen measurement is inappropriate because urine porphobilinogen is used when acute porphyria is suspected, typically with episodic abdominal pain, neuropathy, autonomic symptoms, or dark urine."
            },
            {
              "id": "C",
              "text": "Option C: Copper quantification is inappropriate because urinary copper studies may contribute to evaluation for Wilson disease, which more often produces hepatic disease, movement abnormalities, or a progressive psychiatric presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A urine phencyclidine assay alone is inappropriate because phencyclidine can produce agitation and psychosis, but a PCP-only assay assumes a particular drug despite an unidentified device. A broad toxicology screen is the appropriate initial test."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i023-digeorge-t-cell-deficiency",
      "expectedHashes": {
        "ranaze_step3_uat": "a26378e6cebae1ea7268cec6fa50c17a7276e1abf3b5d483f167d143debb77ec",
        "ranaze_step3_prd": "a26378e6cebae1ea7268cec6fa50c17a7276e1abf3b5d483f167d143debb77ec"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Failure of neutrophil oxidative killing is inappropriate because defective oxidative killing causes recurrent catalase-positive bacterial and fungal infections but does not explain the congenital cardiac defect, hypocalcemia, or absent thymic shadow."
            },
            {
              "id": "B",
              "text": "Option C: Isolated immunoglobulin A deficiency is inappropriate because selective IgA deficiency commonly causes mucosal infections but does not produce this constellation of congenital anomalies or profound opportunistic infection."
            },
            {
              "id": "C",
              "text": "Option D: Defective terminal complement formation is inappropriate because terminal complement deficiency primarily predisposes to recurrent Neisseria infections rather than persistent candidiasis in early infancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Failure of neutrophil oxidative killing is inappropriate because defective oxidative killing causes recurrent catalase-positive bacterial and fungal infections but does not explain the congenital cardiac defect, hypocalcemia, or absent thymic shadow."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isolated immunoglobulin A deficiency is inappropriate because selective IgA deficiency commonly causes mucosal infections but does not produce this constellation of congenital anomalies or profound opportunistic infection."
            },
            {
              "id": "B",
              "text": "Option B: Failure of neutrophil oxidative killing is inappropriate because defective oxidative killing causes recurrent catalase-positive bacterial and fungal infections but does not explain the congenital cardiac defect, hypocalcemia, or absent thymic shadow."
            },
            {
              "id": "C",
              "text": "Option D: Defective terminal complement formation is inappropriate because terminal complement deficiency primarily predisposes to recurrent Neisseria infections rather than persistent candidiasis in early infancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isolated immunoglobulin A deficiency is inappropriate because selective IgA deficiency commonly causes mucosal infections but does not produce this constellation of congenital anomalies or profound opportunistic infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defective terminal complement formation is inappropriate because terminal complement deficiency primarily predisposes to recurrent Neisseria infections rather than persistent candidiasis in early infancy."
            },
            {
              "id": "B",
              "text": "Option B: Failure of neutrophil oxidative killing is inappropriate because defective oxidative killing causes recurrent catalase-positive bacterial and fungal infections but does not explain the congenital cardiac defect, hypocalcemia, or absent thymic shadow."
            },
            {
              "id": "C",
              "text": "Option C: Isolated immunoglobulin A deficiency is inappropriate because selective IgA deficiency commonly causes mucosal infections but does not produce this constellation of congenital anomalies or profound opportunistic infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defective terminal complement formation is inappropriate because terminal complement deficiency primarily predisposes to recurrent Neisseria infections rather than persistent candidiasis in early infancy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Loss of maternal immunoglobulin G before normal B-cell maturation is inappropriate because physiologic decline of maternal IgG is not associated with absent thymic tissue, hypocalcemia, or a conotruncal cardiac malformation."
            },
            {
              "id": "B",
              "text": "Option B: Failure of neutrophil oxidative killing is inappropriate because defective oxidative killing causes recurrent catalase-positive bacterial and fungal infections but does not explain the congenital cardiac defect, hypocalcemia, or absent thymic shadow."
            },
            {
              "id": "C",
              "text": "Option C: Isolated immunoglobulin A deficiency is inappropriate because selective IgA deficiency commonly causes mucosal infections but does not produce this constellation of congenital anomalies or profound opportunistic infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Loss of maternal immunoglobulin G before normal B-cell maturation is inappropriate because physiologic decline of maternal IgG is not associated with absent thymic tissue, hypocalcemia, or a conotruncal cardiac malformation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Adenosine deaminase deficiency causing severe combined immunodeficiency is inappropriate because aDA deficiency can cause profound lymphopenia, candidiasis, and early opportunistic infection, making it a plausible SCID alternative. However, the linked conotruncal defect, micrognathia, hypocalcemia, and absent thymic tissue specifically indicate a pharyngeal-pouch developmental disorder."
            },
            {
              "id": "B",
              "text": "Option B: Failure of neutrophil oxidative killing is inappropriate because defective oxidative killing causes recurrent catalase-positive bacterial and fungal infections but does not explain the congenital cardiac defect, hypocalcemia, or absent thymic shadow."
            },
            {
              "id": "C",
              "text": "Option C: Isolated immunoglobulin A deficiency is inappropriate because selective IgA deficiency commonly causes mucosal infections but does not produce this constellation of congenital anomalies or profound opportunistic infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Adenosine deaminase deficiency causing severe combined immunodeficiency is inappropriate because aDA deficiency can cause profound lymphopenia, candidiasis, and early opportunistic infection, making it a plausible SCID alternative. However, the linked conotruncal defect, micrognathia, hypocalcemia, and absent thymic tissue specifically indicate a pharyngeal-pouch developmental disorder."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i024-remove-inappropriate-urinary-catheter",
      "expectedHashes": {
        "ranaze_step3_uat": "21091c227c30d190f541dca85c8a3cbc3acec96a5fcc52ce0b1e9a8c2ac689d1",
        "ranaze_step3_prd": "21091c227c30d190f541dca85c8a3cbc3acec96a5fcc52ce0b1e9a8c2ac689d1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "B",
              "text": "Option C: Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            },
            {
              "id": "C",
              "text": "Option D: Begin tamsulosin and leave the catheter in place for one week is inappropriate because there is no history suggesting bladder outlet obstruction or retention, so empiric alpha-blocker therapy does not justify continued catheterization."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            },
            {
              "id": "B",
              "text": "Option B: Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "C",
              "text": "Option D: Begin tamsulosin and leave the catheter in place for one week is inappropriate because there is no history suggesting bladder outlet obstruction or retention, so empiric alpha-blocker therapy does not justify continued catheterization."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin tamsulosin and leave the catheter in place for one week is inappropriate because there is no history suggesting bladder outlet obstruction or retention, so empiric alpha-blocker therapy does not justify continued catheterization."
            },
            {
              "id": "B",
              "text": "Option B: Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin tamsulosin and leave the catheter in place for one week is inappropriate because there is no history suggesting bladder outlet obstruction or retention, so empiric alpha-blocker therapy does not justify continued catheterization."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request urologic consultation before changing catheter management is inappropriate because removal of a catheter being used only for incontinence does not require specialist consultation."
            },
            {
              "id": "B",
              "text": "Option B: Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request urologic consultation before changing catheter management is inappropriate because removal of a catheter being used only for incontinence does not require specialist consultation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Leave the catheter in place until he can transfer to the bathroom independently is inappropriate because waiting for independent mobility unnecessarily prolongs catheter exposure. His incontinence has a functional barrier that can be managed immediately with assistance and scheduled toileting; independent transfer is not required before removal."
            },
            {
              "id": "B",
              "text": "Option B: Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Leave the catheter in place until he can transfer to the bathroom independently is inappropriate because waiting for independent mobility unnecessarily prolongs catheter exposure. His incontinence has a functional barrier that can be managed immediately with assistance and scheduled toileting; independent transfer is not required before removal."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Clamp and release the catheter for 24 hours before removing it is inappropriate because bladder training by clamping is unnecessary before removal and prolongs exposure to a catheter that has no ongoing indication. He previously voided independently and has no history suggesting impaired emptying."
            },
            {
              "id": "B",
              "text": "Option B: Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Clamp and release the catheter for 24 hours before removing it is inappropriate because bladder training by clamping is unnecessary before removal and prolongs exposure to a catheter that has no ongoing indication. He previously voided independently and has no history suggesting impaired emptying."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a prophylactic dose of ceftriaxone before catheter removal is inappropriate because routine systemic antimicrobial prophylaxis is not indicated for removal of an unnecessary catheter in an asymptomatic nonsurgical patient. It adds adverse-effect and antimicrobial-resistance risk without treating a demonstrated infection."
            },
            {
              "id": "B",
              "text": "Option B: Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a prophylactic dose of ceftriaxone before catheter removal is inappropriate because routine systemic antimicrobial prophylaxis is not indicated for removal of an unnecessary catheter in an asymptomatic nonsurgical patient. It adds adverse-effect and antimicrobial-resistance risk without treating a demonstrated infection."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remove the catheter and begin intermittent straight catheterization every 6 hours is inappropriate because intermittent catheterization is appropriate for bladder-emptying dysfunction, not uncomplicated functional incontinence. This patient has no history of retention and should first resume assisted spontaneous voiding."
            },
            {
              "id": "B",
              "text": "Option B: Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remove the catheter and begin intermittent straight catheterization every 6 hours is inappropriate because intermittent catheterization is appropriate for bladder-emptying dysfunction, not uncomplicated functional incontinence. This patient has no history of retention and should first resume assisted spontaneous voiding."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue the catheter with daily antimicrobial bladder irrigation is inappropriate because routine antimicrobial bladder irrigation is not recommended for CAUTI prevention. More importantly, irrigation perpetuates an indwelling catheter that was placed solely for incontinence and should be removed."
            },
            {
              "id": "B",
              "text": "Option B: Replace it now and continue chronic catheter drainage is inappropriate because routine replacement perpetuates unnecessary catheter exposure and its complications."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a urine culture before deciding whether to remove it is inappropriate because clear urine in an asymptomatic catheterized patient does not warrant screening culture, and culture is not required before catheter removal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue the catheter with daily antimicrobial bladder irrigation is inappropriate because routine antimicrobial bladder irrigation is not recommended for CAUTI prevention. More importantly, irrigation perpetuates an indwelling catheter that was placed solely for incontinence and should be removed."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i026-blue-toe-arterial-embolization",
      "expectedHashes": {
        "ranaze_step3_uat": "901ea2bafa8e0d9a784c0faca4deb452fa54235fa362d67381065f2f6dd7cbb6",
        "ranaze_step3_prd": "901ea2bafa8e0d9a784c0faca4deb452fa54235fa362d67381065f2f6dd7cbb6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inflammatory destruction of small arteries is inappropriate because arteritis can cause digital ischemia but is less likely without systemic inflammatory features and does not explain the pulsatile popliteal mass."
            },
            {
              "id": "B",
              "text": "Option C: Progressive atherosclerotic occlusion of the proximal limb arteries is inappropriate because advanced proximal occlusive disease generally causes diminished distal pulses, a cool extremity, claudication, or more extensive ischemia."
            },
            {
              "id": "C",
              "text": "Option D: Noninflammatory thrombosis of superficial digital vessels is inappropriate because obliterative angiopathy is more characteristic of younger tobacco users and typically involves distal pulses and multiple extremities."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inflammatory destruction of small arteries is inappropriate because arteritis can cause digital ischemia but is less likely without systemic inflammatory features and does not explain the pulsatile popliteal mass."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Progressive atherosclerotic occlusion of the proximal limb arteries is inappropriate because advanced proximal occlusive disease generally causes diminished distal pulses, a cool extremity, claudication, or more extensive ischemia."
            },
            {
              "id": "B",
              "text": "Option B: Inflammatory destruction of small arteries is inappropriate because arteritis can cause digital ischemia but is less likely without systemic inflammatory features and does not explain the pulsatile popliteal mass."
            },
            {
              "id": "C",
              "text": "Option D: Noninflammatory thrombosis of superficial digital vessels is inappropriate because obliterative angiopathy is more characteristic of younger tobacco users and typically involves distal pulses and multiple extremities."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Progressive atherosclerotic occlusion of the proximal limb arteries is inappropriate because advanced proximal occlusive disease generally causes diminished distal pulses, a cool extremity, claudication, or more extensive ischemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Noninflammatory thrombosis of superficial digital vessels is inappropriate because obliterative angiopathy is more characteristic of younger tobacco users and typically involves distal pulses and multiple extremities."
            },
            {
              "id": "B",
              "text": "Option B: Inflammatory destruction of small arteries is inappropriate because arteritis can cause digital ischemia but is less likely without systemic inflammatory features and does not explain the pulsatile popliteal mass."
            },
            {
              "id": "C",
              "text": "Option C: Progressive atherosclerotic occlusion of the proximal limb arteries is inappropriate because advanced proximal occlusive disease generally causes diminished distal pulses, a cool extremity, claudication, or more extensive ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Noninflammatory thrombosis of superficial digital vessels is inappropriate because obliterative angiopathy is more characteristic of younger tobacco users and typically involves distal pulses and multiple extremities."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reversible digital vasospasm is inappropriate because raynaud phenomenon produces episodic, reversible color changes triggered by cold or stress rather than fixed dry gangrene associated with a pulsatile mass."
            },
            {
              "id": "B",
              "text": "Option B: Inflammatory destruction of small arteries is inappropriate because arteritis can cause digital ischemia but is less likely without systemic inflammatory features and does not explain the pulsatile popliteal mass."
            },
            {
              "id": "C",
              "text": "Option C: Progressive atherosclerotic occlusion of the proximal limb arteries is inappropriate because advanced proximal occlusive disease generally causes diminished distal pulses, a cool extremity, claudication, or more extensive ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reversible digital vasospasm is inappropriate because raynaud phenomenon produces episodic, reversible color changes triggered by cold or stress rather than fixed dry gangrene associated with a pulsatile mass."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Complete in situ thrombosis of the popliteal artery aneurysm is inappropriate because complete thrombosis of a popliteal aneurysm can cause acute limb ischemia, but it would impair downstream perfusion and generally produce a painful, cool limb with diminished distal pulses. This patient\u0027s warm foot and readily palpable pedal pulses instead indicate preserved flow through the major arteries with focal distal embolization."
            },
            {
              "id": "B",
              "text": "Option B: Inflammatory destruction of small arteries is inappropriate because arteritis can cause digital ischemia but is less likely without systemic inflammatory features and does not explain the pulsatile popliteal mass."
            },
            {
              "id": "C",
              "text": "Option C: Progressive atherosclerotic occlusion of the proximal limb arteries is inappropriate because advanced proximal occlusive disease generally causes diminished distal pulses, a cool extremity, claudication, or more extensive ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Complete in situ thrombosis of the popliteal artery aneurysm is inappropriate because complete thrombosis of a popliteal aneurysm can cause acute limb ischemia, but it would impair downstream perfusion and generally produce a painful, cool limb with diminished distal pulses. This patient\u0027s warm foot and readily palpable pedal pulses instead indicate preserved flow through the major arteries with focal distal embolization."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Calcific uremic arteriolopathy of dermal arterioles is inappropriate because chronic kidney disease makes calcific uremic arteriolopathy superficially plausible, but calciphylaxis typically produces intensely painful, indurated or retiform skin lesions rather than isolated painless digital gangrene associated with a pulsatile popliteal mass and bruit."
            },
            {
              "id": "B",
              "text": "Option B: Inflammatory destruction of small arteries is inappropriate because arteritis can cause digital ischemia but is less likely without systemic inflammatory features and does not explain the pulsatile popliteal mass."
            },
            {
              "id": "C",
              "text": "Option C: Progressive atherosclerotic occlusion of the proximal limb arteries is inappropriate because advanced proximal occlusive disease generally causes diminished distal pulses, a cool extremity, claudication, or more extensive ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Calcific uremic arteriolopathy of dermal arterioles is inappropriate because chronic kidney disease makes calcific uremic arteriolopathy superficially plausible, but calciphylaxis typically produces intensely painful, indurated or retiform skin lesions rather than isolated painless digital gangrene associated with a pulsatile popliteal mass and bruit."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i028-status-asthmaticus-intubation",
      "expectedHashes": {
        "ranaze_step3_uat": "3d6e25b7f6640b3627e6806a8a8df50a349145a7faa1d13b761f4367e688b55d",
        "ranaze_step3_prd": "3d6e25b7f6640b3627e6806a8a8df50a349145a7faa1d13b761f4367e688b55d"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulse of 128/min is inappropriate because tachycardia is common during severe asthma and may be intensified by beta-agonist therapy; by itself, it does not mandate intubation."
            },
            {
              "id": "B",
              "text": "Option B: Respiratory rate of 34/min is inappropriate because tachypnea indicates significant respiratory distress but does not alone establish ventilatory failure or loss of airway protection."
            },
            {
              "id": "C",
              "text": "Option C: Persistent chest tightness is inappropriate because chest tightness is a common asthma symptom and is not independently an indication for invasive ventilation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulse of 128/min is inappropriate because tachycardia is common during severe asthma and may be intensified by beta-agonist therapy; by itself, it does not mandate intubation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Respiratory rate of 34/min is inappropriate because tachypnea indicates significant respiratory distress but does not alone establish ventilatory failure or loss of airway protection."
            },
            {
              "id": "B",
              "text": "Option A: Pulse of 128/min is inappropriate because tachycardia is common during severe asthma and may be intensified by beta-agonist therapy; by itself, it does not mandate intubation."
            },
            {
              "id": "C",
              "text": "Option C: Persistent chest tightness is inappropriate because chest tightness is a common asthma symptom and is not independently an indication for invasive ventilation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Respiratory rate of 34/min is inappropriate because tachypnea indicates significant respiratory distress but does not alone establish ventilatory failure or loss of airway protection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Persistent chest tightness is inappropriate because chest tightness is a common asthma symptom and is not independently an indication for invasive ventilation."
            },
            {
              "id": "B",
              "text": "Option A: Pulse of 128/min is inappropriate because tachycardia is common during severe asthma and may be intensified by beta-agonist therapy; by itself, it does not mandate intubation."
            },
            {
              "id": "C",
              "text": "Option B: Respiratory rate of 34/min is inappropriate because tachypnea indicates significant respiratory distress but does not alone establish ventilatory failure or loss of airway protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Persistent chest tightness is inappropriate because chest tightness is a common asthma symptom and is not independently an indication for invasive ventilation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Initial prominent wheezing is inappropriate because prominent wheezing reflects airflow through narrowed airways; the later fading of wheezing with reduced effort is more concerning for minimal airflow and fatigue."
            },
            {
              "id": "B",
              "text": "Option A: Pulse of 128/min is inappropriate because tachycardia is common during severe asthma and may be intensified by beta-agonist therapy; by itself, it does not mandate intubation."
            },
            {
              "id": "C",
              "text": "Option B: Respiratory rate of 34/min is inappropriate because tachypnea indicates significant respiratory distress but does not alone establish ventilatory failure or loss of airway protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Initial prominent wheezing is inappropriate because prominent wheezing reflects airflow through narrowed airways; the later fading of wheezing with reduced effort is more concerning for minimal airflow and fatigue."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Failure to improve after 20 minutes of intensive medical therapy is inappropriate because failure to respond to bronchodilators, systemic glucocorticoids, and magnesium indicates refractory severe asthma, but a short interval of persistent symptoms alone does not mandate intubation. The new neurologic deterioration does."
            },
            {
              "id": "B",
              "text": "Option A: Pulse of 128/min is inappropriate because tachycardia is common during severe asthma and may be intensified by beta-agonist therapy; by itself, it does not mandate intubation."
            },
            {
              "id": "C",
              "text": "Option B: Respiratory rate of 34/min is inappropriate because tachypnea indicates significant respiratory distress but does not alone establish ventilatory failure or loss of airway protection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Failure to improve after 20 minutes of intensive medical therapy is inappropriate because failure to respond to bronchodilators, systemic glucocorticoids, and magnesium indicates refractory severe asthma, but a short interval of persistent symptoms alone does not mandate intubation. The new neurologic deterioration does."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i029-ethylene-glycol-poisoning",
      "expectedHashes": {
        "ranaze_step3_uat": "750716c54fa60f24bf22d21b5460d6f22b2b32e5c74c10ac7fea3497c4e2cc1c",
        "ranaze_step3_prd": "750716c54fa60f24bf22d21b5460d6f22b2b32e5c74c10ac7fea3497c4e2cc1c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isopropyl alcohol causes intoxication and ketosis but typically does not produce a high-anion-gap metabolic acidosis."
            },
            {
              "id": "B",
              "text": "Option C: Carbon monoxide commonly causes headache and neurologic symptoms, but it does not explain the severe metabolic acidosis with calcium oxalate crystals."
            },
            {
              "id": "C",
              "text": "Option D: Methanol produces high-anion-gap acidosis and prominent ocular toxicity, but calcium oxalate crystalluria and access to engine coolant favor ethylene glycol."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isopropyl alcohol causes intoxication and ketosis but typically does not produce a high-anion-gap metabolic acidosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carbon monoxide commonly causes headache and neurologic symptoms, but it does not explain the severe metabolic acidosis with calcium oxalate crystals."
            },
            {
              "id": "B",
              "text": "Option B: Isopropyl alcohol causes intoxication and ketosis but typically does not produce a high-anion-gap metabolic acidosis."
            },
            {
              "id": "C",
              "text": "Option D: Methanol produces high-anion-gap acidosis and prominent ocular toxicity, but calcium oxalate crystalluria and access to engine coolant favor ethylene glycol."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carbon monoxide commonly causes headache and neurologic symptoms, but it does not explain the severe metabolic acidosis with calcium oxalate crystals."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Methanol produces high-anion-gap acidosis and prominent ocular toxicity, but calcium oxalate crystalluria and access to engine coolant favor ethylene glycol."
            },
            {
              "id": "B",
              "text": "Option B: Isopropyl alcohol causes intoxication and ketosis but typically does not produce a high-anion-gap metabolic acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Carbon monoxide commonly causes headache and neurologic symptoms, but it does not explain the severe metabolic acidosis with calcium oxalate crystals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Methanol produces high-anion-gap acidosis and prominent ocular toxicity, but calcium oxalate crystalluria and access to engine coolant favor ethylene glycol."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Salicylates is inappropriate because salicylate toxicity usually produces a mixed respiratory alkalosis and metabolic acidosis, often with tinnitus, diaphoresis, and hyperventilation."
            },
            {
              "id": "B",
              "text": "Option B: Isopropyl alcohol causes intoxication and ketosis but typically does not produce a high-anion-gap metabolic acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Carbon monoxide commonly causes headache and neurologic symptoms, but it does not explain the severe metabolic acidosis with calcium oxalate crystals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Salicylates is inappropriate because salicylate toxicity usually produces a mixed respiratory alkalosis and metabolic acidosis, often with tinnitus, diaphoresis, and hyperventilation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ethanol can cause intoxication, dysarthria, ataxia, vomiting, and an increased osmolal gap. However, ethanol intoxication alone does not explain this profound high-anion-gap metabolic acidosis with envelope-shaped calcium oxalate crystals; those crystals specifically support ethylene glycol metabolism."
            },
            {
              "id": "B",
              "text": "Option B: Isopropyl alcohol causes intoxication and ketosis but typically does not produce a high-anion-gap metabolic acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Carbon monoxide commonly causes headache and neurologic symptoms, but it does not explain the severe metabolic acidosis with calcium oxalate crystals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ethanol can cause intoxication, dysarthria, ataxia, vomiting, and an increased osmolal gap. However, ethanol intoxication alone does not explain this profound high-anion-gap metabolic acidosis with envelope-shaped calcium oxalate crystals; those crystals specifically support ethylene glycol metabolism."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Toluene exposure can cause CNS depression and metabolic acidosis, particularly in solvent inhalation or chronic abuse, and is often associated with hypokalemia or renal tubular acidosis. It does not account for envelope-shaped calcium oxalate crystals beside an open container of engine coolant."
            },
            {
              "id": "B",
              "text": "Option B: Isopropyl alcohol causes intoxication and ketosis but typically does not produce a high-anion-gap metabolic acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Carbon monoxide commonly causes headache and neurologic symptoms, but it does not explain the severe metabolic acidosis with calcium oxalate crystals."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Toluene exposure can cause CNS depression and metabolic acidosis, particularly in solvent inhalation or chronic abuse, and is often associated with hypokalemia or renal tubular acidosis. It does not account for envelope-shaped calcium oxalate crystals beside an open container of engine coolant."
        }
      }
    },
    {
      "externalId": "nbme5-s1-i032-congenital-accessory-pathway",
      "expectedHashes": {
        "ranaze_step3_uat": "ec953f900b118f9751e4744ec8a481e7b95121f27530c8b379003a09d3e3662a",
        "ranaze_step3_prd": "ec953f900b118f9751e4744ec8a481e7b95121f27530c8b379003a09d3e3662a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Catecholamine excess from stimulant exposure is inappropriate because stimulants can cause tachycardia, but the patient denies their use and the postconversion short PR interval with a slurred QRS upstroke indicates preexcitation."
            },
            {
              "id": "B",
              "text": "Option C: Inflammatory atrioventricular nodal injury following viral myocarditis is inappropriate because myocarditis may produce arrhythmias and conduction block, but no preceding viral illness is described and its conduction abnormalities do not produce this characteristic preexcitation pattern."
            },
            {
              "id": "C",
              "text": "Option D: Right ventricular strain caused by pulmonary embolism is inappropriate because pulmonary embolism generally causes sinus tachycardia with respiratory findings or hypoxemia rather than recurrent abrupt-onset, adenosine-responsive narrow-complex tachycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Catecholamine excess from stimulant exposure is inappropriate because stimulants can cause tachycardia, but the patient denies their use and the postconversion short PR interval with a slurred QRS upstroke indicates preexcitation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inflammatory atrioventricular nodal injury following viral myocarditis is inappropriate because myocarditis may produce arrhythmias and conduction block, but no preceding viral illness is described and its conduction abnormalities do not produce this characteristic preexcitation pattern."
            },
            {
              "id": "B",
              "text": "Option B: Catecholamine excess from stimulant exposure is inappropriate because stimulants can cause tachycardia, but the patient denies their use and the postconversion short PR interval with a slurred QRS upstroke indicates preexcitation."
            },
            {
              "id": "C",
              "text": "Option D: Right ventricular strain caused by pulmonary embolism is inappropriate because pulmonary embolism generally causes sinus tachycardia with respiratory findings or hypoxemia rather than recurrent abrupt-onset, adenosine-responsive narrow-complex tachycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inflammatory atrioventricular nodal injury following viral myocarditis is inappropriate because myocarditis may produce arrhythmias and conduction block, but no preceding viral illness is described and its conduction abnormalities do not produce this characteristic preexcitation pattern."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Right ventricular strain caused by pulmonary embolism is inappropriate because pulmonary embolism generally causes sinus tachycardia with respiratory findings or hypoxemia rather than recurrent abrupt-onset, adenosine-responsive narrow-complex tachycardia."
            },
            {
              "id": "B",
              "text": "Option B: Catecholamine excess from stimulant exposure is inappropriate because stimulants can cause tachycardia, but the patient denies their use and the postconversion short PR interval with a slurred QRS upstroke indicates preexcitation."
            },
            {
              "id": "C",
              "text": "Option C: Inflammatory atrioventricular nodal injury following viral myocarditis is inappropriate because myocarditis may produce arrhythmias and conduction block, but no preceding viral illness is described and its conduction abnormalities do not produce this characteristic preexcitation pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Right ventricular strain caused by pulmonary embolism is inappropriate because pulmonary embolism generally causes sinus tachycardia with respiratory findings or hypoxemia rather than recurrent abrupt-onset, adenosine-responsive narrow-complex tachycardia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Autonomous thyroid hormone secretion is inappropriate because hyperthyroidism commonly causes persistent sinus tachycardia or atrial fibrillation, not a short PR interval with a slurred initial QRS upstroke."
            },
            {
              "id": "B",
              "text": "Option B: Catecholamine excess from stimulant exposure is inappropriate because stimulants can cause tachycardia, but the patient denies their use and the postconversion short PR interval with a slurred QRS upstroke indicates preexcitation."
            },
            {
              "id": "C",
              "text": "Option C: Inflammatory atrioventricular nodal injury following viral myocarditis is inappropriate because myocarditis may produce arrhythmias and conduction block, but no preceding viral illness is described and its conduction abnormalities do not produce this characteristic preexcitation pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Autonomous thyroid hormone secretion is inappropriate because hyperthyroidism commonly causes persistent sinus tachycardia or atrial fibrillation, not a short PR interval with a slurred initial QRS upstroke."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dual atrioventricular nodal pathways permitting nodal reentry is inappropriate because dual AV nodal pathways predispose to AV nodal reentrant tachycardia, another abrupt, regular, adenosine-responsive narrow-complex tachycardia. However, they do not explain ventricular preexcitation during sinus rhythm; the 90-millisecond PR interval and slurred initial QRS upstroke identify conduction through a manifest accessory AV pathway."
            },
            {
              "id": "B",
              "text": "Option B: Catecholamine excess from stimulant exposure is inappropriate because stimulants can cause tachycardia, but the patient denies their use and the postconversion short PR interval with a slurred QRS upstroke indicates preexcitation."
            },
            {
              "id": "C",
              "text": "Option C: Inflammatory atrioventricular nodal injury following viral myocarditis is inappropriate because myocarditis may produce arrhythmias and conduction block, but no preceding viral illness is described and its conduction abnormalities do not produce this characteristic preexcitation pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dual atrioventricular nodal pathways permitting nodal reentry is inappropriate because dual AV nodal pathways predispose to AV nodal reentrant tachycardia, another abrupt, regular, adenosine-responsive narrow-complex tachycardia. However, they do not explain ventricular preexcitation during sinus rhythm; the 90-millisecond PR interval and slurred initial QRS upstroke identify conduction through a manifest accessory AV pathway."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Enhanced automaticity of a focal atrial pacemaker is inappropriate because focal atrial tachycardia can be regular and narrow-complex, but it is generated within the atrium rather than by an accessory AV connection. Adenosine may transiently suppress some automatic foci, but focal atrial automaticity does not produce a short PR interval with a delta wave after conversion."
            },
            {
              "id": "B",
              "text": "Option B: Catecholamine excess from stimulant exposure is inappropriate because stimulants can cause tachycardia, but the patient denies their use and the postconversion short PR interval with a slurred QRS upstroke indicates preexcitation."
            },
            {
              "id": "C",
              "text": "Option C: Inflammatory atrioventricular nodal injury following viral myocarditis is inappropriate because myocarditis may produce arrhythmias and conduction block, but no preceding viral illness is described and its conduction abnormalities do not produce this characteristic preexcitation pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Enhanced automaticity of a focal atrial pacemaker is inappropriate because focal atrial tachycardia can be regular and narrow-complex, but it is generated within the atrium rather than by an accessory AV connection. Adenosine may transiently suppress some automatic foci, but focal atrial automaticity does not produce a short PR interval with a delta wave after conversion."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i002-vitamin-b12-macroovalocytes",
      "expectedHashes": {
        "ranaze_step3_uat": "252007696ff3fc369f965d4a5e58712662065cb1b141f4efe53900b652356795",
        "ranaze_step3_prd": "252007696ff3fc369f965d4a5e58712662065cb1b141f4efe53900b652356795"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sickle-shaped cells with pointed ends is inappropriate because sickle cells result from polymerization of hemoglobin S and are not a feature of vitamin B12 deficiency."
            },
            {
              "id": "B",
              "text": "Option B: Small dense cells without central pallor is inappropriate because spherocytes occur with membrane loss, such as in hereditary spherocytosis or immune hemolysis, rather than megaloblastic anemia."
            },
            {
              "id": "C",
              "text": "Option D: Erythrocytes with irregular thorn-like projections is inappropriate because acanthocytes are associated with severe liver disease, abetalipoproteinemia, and selected neurodegenerative disorders."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sickle-shaped cells with pointed ends is inappropriate because sickle cells result from polymerization of hemoglobin S and are not a feature of vitamin B12 deficiency."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Small dense cells without central pallor is inappropriate because spherocytes occur with membrane loss, such as in hereditary spherocytosis or immune hemolysis, rather than megaloblastic anemia."
            },
            {
              "id": "B",
              "text": "Option A: Sickle-shaped cells with pointed ends is inappropriate because sickle cells result from polymerization of hemoglobin S and are not a feature of vitamin B12 deficiency."
            },
            {
              "id": "C",
              "text": "Option D: Erythrocytes with irregular thorn-like projections is inappropriate because acanthocytes are associated with severe liver disease, abetalipoproteinemia, and selected neurodegenerative disorders."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Small dense cells without central pallor is inappropriate because spherocytes occur with membrane loss, such as in hereditary spherocytosis or immune hemolysis, rather than megaloblastic anemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Erythrocytes with irregular thorn-like projections is inappropriate because acanthocytes are associated with severe liver disease, abetalipoproteinemia, and selected neurodegenerative disorders."
            },
            {
              "id": "B",
              "text": "Option A: Sickle-shaped cells with pointed ends is inappropriate because sickle cells result from polymerization of hemoglobin S and are not a feature of vitamin B12 deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Small dense cells without central pallor is inappropriate because spherocytes occur with membrane loss, such as in hereditary spherocytosis or immune hemolysis, rather than megaloblastic anemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Erythrocytes with irregular thorn-like projections is inappropriate because acanthocytes are associated with severe liver disease, abetalipoproteinemia, and selected neurodegenerative disorders."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Erythrocytes with a central island of hemoglobin is inappropriate because target cells occur when the membrane-to-hemoglobin ratio is increased, as in thalassemia, liver disease, or hyposplenism."
            },
            {
              "id": "B",
              "text": "Option A: Sickle-shaped cells with pointed ends is inappropriate because sickle cells result from polymerization of hemoglobin S and are not a feature of vitamin B12 deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Small dense cells without central pallor is inappropriate because spherocytes occur with membrane loss, such as in hereditary spherocytosis or immune hemolysis, rather than megaloblastic anemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Erythrocytes with a central island of hemoglobin is inappropriate because target cells occur when the membrane-to-hemoglobin ratio is increased, as in thalassemia, liver disease, or hyposplenism."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Teardrop-shaped erythrocytes is inappropriate because teardrop cells are most strongly associated with marrow distortion or infiltration, particularly myelofibrosis. The findings here instead identify megaloblastic anemia from vitamin B12 deficiency."
            },
            {
              "id": "B",
              "text": "Option A: Sickle-shaped cells with pointed ends is inappropriate because sickle cells result from polymerization of hemoglobin S and are not a feature of vitamin B12 deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Small dense cells without central pallor is inappropriate because spherocytes occur with membrane loss, such as in hereditary spherocytosis or immune hemolysis, rather than megaloblastic anemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Teardrop-shaped erythrocytes is inappropriate because teardrop cells are most strongly associated with marrow distortion or infiltration, particularly myelofibrosis. The findings here instead identify megaloblastic anemia from vitamin B12 deficiency."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Erythrocytes arranged in coin-like stacks is inappropriate because rouleaux formation reflects increased plasma proteins, as in plasma cell dyscrasias or marked inflammation. It does not explain the macrocytosis, neurologic dysfunction, low vitamin B12, and intrinsic-factor antibodies."
            },
            {
              "id": "B",
              "text": "Option A: Sickle-shaped cells with pointed ends is inappropriate because sickle cells result from polymerization of hemoglobin S and are not a feature of vitamin B12 deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Small dense cells without central pallor is inappropriate because spherocytes occur with membrane loss, such as in hereditary spherocytosis or immune hemolysis, rather than megaloblastic anemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Erythrocytes arranged in coin-like stacks is inappropriate because rouleaux formation reflects increased plasma proteins, as in plasma cell dyscrasias or marked inflammation. It does not explain the macrocytosis, neurologic dysfunction, low vitamin B12, and intrinsic-factor antibodies."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Small pale erythrocytes with increased central pallor is inappropriate because microcytic, hypochromic erythrocytes suggest impaired hemoglobin production, such as iron deficiency or thalassemia. This patient\u0027s MCV of 116 fL establishes macrocytosis."
            },
            {
              "id": "B",
              "text": "Option A: Sickle-shaped cells with pointed ends is inappropriate because sickle cells result from polymerization of hemoglobin S and are not a feature of vitamin B12 deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Small dense cells without central pallor is inappropriate because spherocytes occur with membrane loss, such as in hereditary spherocytosis or immune hemolysis, rather than megaloblastic anemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Small pale erythrocytes with increased central pallor is inappropriate because microcytic, hypochromic erythrocytes suggest impaired hemoglobin production, such as iron deficiency or thalassemia. This patient\u0027s MCV of 116 fL establishes macrocytosis."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i004-early-vitamin-k-deficiency-bleeding",
      "expectedHashes": {
        "ranaze_step3_uat": "4812ff92a5f6f886f353997020bdfb06cb650b9c9e711b0d5ead4a27dd1bdbd7",
        "ranaze_step3_prd": "4812ff92a5f6f886f353997020bdfb06cb650b9c9e711b0d5ead4a27dd1bdbd7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
            },
            {
              "id": "B",
              "text": "Option B: Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
            },
            {
              "id": "C",
              "text": "Option D: Inherited absence of coagulation factor VIII is inappropriate because hemophilia A typically causes an isolated prolonged activated partial thromboplastin time and does not usually produce bleeding during the first few days after uncomplicated birth."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
            },
            {
              "id": "B",
              "text": "Option A: Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
            },
            {
              "id": "C",
              "text": "Option D: Inherited absence of coagulation factor VIII is inappropriate because hemophilia A typically causes an isolated prolonged activated partial thromboplastin time and does not usually produce bleeding during the first few days after uncomplicated birth."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inherited absence of coagulation factor VIII is inappropriate because hemophilia A typically causes an isolated prolonged activated partial thromboplastin time and does not usually produce bleeding during the first few days after uncomplicated birth."
            },
            {
              "id": "B",
              "text": "Option A: Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
            },
            {
              "id": "C",
              "text": "Option B: Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inherited absence of coagulation factor VIII is inappropriate because hemophilia A typically causes an isolated prolonged activated partial thromboplastin time and does not usually produce bleeding during the first few days after uncomplicated birth."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bone marrow suppression caused by congenital infection is inappropriate because congenital infection can cause thrombocytopenia, growth abnormalities, hepatosplenomegaly, or other systemic findings, none of which are present."
            },
            {
              "id": "B",
              "text": "Option A: Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
            },
            {
              "id": "C",
              "text": "Option B: Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bone marrow suppression caused by congenital infection is inappropriate because congenital infection can cause thrombocytopenia, growth abnormalities, hepatosplenomegaly, or other systemic findings, none of which are present."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defective platelet adhesion due to von Willebrand factor deficiency is inappropriate because von Willebrand disease causes defective platelet adhesion and can sometimes prolong the activated partial thromboplastin time through reduced factor VIII stability, but it does not cause an isolated marked PT elevation. The newborn prophylaxis history and carbamazepine exposure instead indicate vitamin K deficiency."
            },
            {
              "id": "B",
              "text": "Option A: Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
            },
            {
              "id": "C",
              "text": "Option B: Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defective platelet adhesion due to von Willebrand factor deficiency is inappropriate because von Willebrand disease causes defective platelet adhesion and can sometimes prolong the activated partial thromboplastin time through reduced factor VIII stability, but it does not cause an isolated marked PT elevation. The newborn prophylaxis history and carbamazepine exposure instead indicate vitamin K deficiency."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Failure to cross-link fibrin due to coagulation factor XIII deficiency is inappropriate because factor XIII acts after fibrin formation, so its deficiency can cause delayed neonatal or umbilical bleeding despite normal routine PT and aPTT. It cannot explain the PT of 28 seconds."
            },
            {
              "id": "B",
              "text": "Option A: Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
            },
            {
              "id": "C",
              "text": "Option B: Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Failure to cross-link fibrin due to coagulation factor XIII deficiency is inappropriate because factor XIII acts after fibrin formation, so its deficiency can cause delayed neonatal or umbilical bleeding despite normal routine PT and aPTT. It cannot explain the PT of 28 seconds."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inherited absence of fibrinogen is inappropriate because congenital afibrinogenemia can cause severe neonatal bleeding, but the absence of fibrinogen impairs both common-pathway assays and therefore prolongs both PT and aPTT. This infant\u0027s aPTT is normal."
            },
            {
              "id": "B",
              "text": "Option A: Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
            },
            {
              "id": "C",
              "text": "Option B: Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inherited absence of fibrinogen is inappropriate because congenital afibrinogenemia can cause severe neonatal bleeding, but the absence of fibrinogen impairs both common-pathway assays and therefore prolongs both PT and aPTT. This infant\u0027s aPTT is normal."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Swallowed maternal blood from the delivery is inappropriate because swallowed maternal blood can produce neonatal hematemesis but cannot account for persistent bleeding from a heel puncture, ecchymoses, or a prolonged PT."
            },
            {
              "id": "B",
              "text": "Option A: Consumption of platelets and coagulation factors due to systemic activation of coagulation is inappropriate because disseminated intravascular coagulation generally occurs in a critically ill infant and causes thrombocytopenia as well as prolonged coagulation studies."
            },
            {
              "id": "C",
              "text": "Option B: Maternal antibodies directed against fetal platelet antigens is inappropriate because neonatal alloimmune thrombocytopenia causes severe thrombocytopenia rather than an isolated increase in prothrombin time."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Swallowed maternal blood from the delivery is inappropriate because swallowed maternal blood can produce neonatal hematemesis but cannot account for persistent bleeding from a heel puncture, ecchymoses, or a prolonged PT."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i007-antimuscarinic-adverse-effects",
      "expectedHashes": {
        "ranaze_step3_uat": "d36e808287dfa8939c78689902fcc2be6ca11ef4896b6db6dc17b606f993a3d7",
        "ranaze_step3_prd": "d36e808287dfa8939c78689902fcc2be6ca11ef4896b6db6dc17b606f993a3d7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "B",
              "text": "Option C: Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            },
            {
              "id": "C",
              "text": "Option D: Excessive serotonin receptor stimulation is inappropriate because serotonin toxicity produces neuromuscular hyperactivity such as clonus and hyperreflexia, often with diaphoresis and increased bowel activity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            },
            {
              "id": "B",
              "text": "Option A: Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "C",
              "text": "Option D: Excessive serotonin receptor stimulation is inappropriate because serotonin toxicity produces neuromuscular hyperactivity such as clonus and hyperreflexia, often with diaphoresis and increased bowel activity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Excessive serotonin receptor stimulation is inappropriate because serotonin toxicity produces neuromuscular hyperactivity such as clonus and hyperreflexia, often with diaphoresis and increased bowel activity."
            },
            {
              "id": "B",
              "text": "Option A: Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "C",
              "text": "Option C: Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Excessive serotonin receptor stimulation is inappropriate because serotonin toxicity produces neuromuscular hyperactivity such as clonus and hyperreflexia, often with diaphoresis and increased bowel activity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Uncoupling of mitochondrial oxidative phosphorylation is inappropriate because oxidative phosphorylation uncoupling, as in salicylate toxicity, causes marked heat production, tachypnea, and acid-base disturbances rather than this dry antimuscarinic syndrome."
            },
            {
              "id": "B",
              "text": "Option A: Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "C",
              "text": "Option C: Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Uncoupling of mitochondrial oxidative phosphorylation is inappropriate because oxidative phosphorylation uncoupling, as in salicylate toxicity, causes marked heat production, tachypnea, and acid-base disturbances rather than this dry antimuscarinic syndrome."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Histamine H1 receptor blockade is inappropriate because h1 blockade explains diphenhydramine-associated sedation but not the coordinated peripheral findings of mydriasis, dry mucosa, urinary retention, and decreased bowel motility, which arise from muscarinic blockade."
            },
            {
              "id": "B",
              "text": "Option A: Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "C",
              "text": "Option C: Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Histamine H1 receptor blockade is inappropriate because h1 blockade explains diphenhydramine-associated sedation but not the coordinated peripheral findings of mydriasis, dry mucosa, urinary retention, and decreased bowel motility, which arise from muscarinic blockade."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Beta-1 adrenergic receptor stimulation is inappropriate because beta-1 stimulation could cause tachycardia but would not explain dry mucosa, mydriasis, urinary retention, and reduced bowel sounds."
            },
            {
              "id": "B",
              "text": "Option A: Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "C",
              "text": "Option C: Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Beta-1 adrenergic receptor stimulation is inappropriate because beta-1 stimulation could cause tachycardia but would not explain dry mucosa, mydriasis, urinary retention, and reduced bowel sounds."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acetylcholinesterase inhibition increases acetylcholine and causes a cholinergic syndrome with miosis, secretions, urination, and increased gastrointestinal activity\u2014the opposite of this patient\u0027s findings."
            },
            {
              "id": "B",
              "text": "Option A: Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "C",
              "text": "Option C: Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acetylcholinesterase inhibition increases acetylcholine and causes a cholinergic syndrome with miosis, secretions, urination, and increased gastrointestinal activity\u2014the opposite of this patient\u0027s findings."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mu-opioid receptor stimulation is inappropriate because mu-opioid stimulation typically causes miosis, respiratory depression, and decreased consciousness. The patient\u0027s dilated pupils, dry skin, normal respiratory rate, and urinary retention favor antimuscarinic toxicity."
            },
            {
              "id": "B",
              "text": "Option A: Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "C",
              "text": "Option C: Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mu-opioid receptor stimulation is inappropriate because mu-opioid stimulation typically causes miosis, respiratory depression, and decreased consciousness. The patient\u0027s dilated pupils, dry skin, normal respiratory rate, and urinary retention favor antimuscarinic toxicity."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inhibition of norepinephrine reuptake is inappropriate because norepinephrine reuptake inhibition can cause tachycardia, hypertension, mydriasis, hyperthermia, and agitation, but sympathomimetic toxicity usually produces diaphoresis rather than markedly dry skin and mucosa and does not characteristically cause ileus with urinary retention."
            },
            {
              "id": "B",
              "text": "Option A: Alpha-1 adrenergic receptor blockade is inappropriate because alpha-1 blockade primarily causes vasodilation and orthostatic hypotension, not dry mucosa, mydriasis, reduced bowel sounds, and urinary retention."
            },
            {
              "id": "C",
              "text": "Option C: Dopamine D2 receptor blockade is inappropriate because dopamine D2 blockade can cause extrapyramidal symptoms, hyperprolactinemia, and neuroleptic malignant syndrome but does not explain the complete antimuscarinic pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inhibition of norepinephrine reuptake is inappropriate because norepinephrine reuptake inhibition can cause tachycardia, hypertension, mydriasis, hyperthermia, and agitation, but sympathomimetic toxicity usually produces diaphoresis rather than markedly dry skin and mucosa and does not characteristically cause ileus with urinary retention."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i008-clinical-trial-outcome-interpretation",
      "expectedHashes": {
        "ranaze_step3_uat": "3cfd54b78868b36e4550e04bc72fdad583b0f55e920ac94e537128f1b6c6f2a7",
        "ranaze_step3_prd": "3cfd54b78868b36e4550e04bc72fdad583b0f55e920ac94e537128f1b6c6f2a7"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "B",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            },
            {
              "id": "C",
              "text": "Option D: The findings cannot be interpreted without knowing whether every participant had identical symptom severity is inappropriate because randomization permits comparison between groups without requiring all participants to have identical baseline symptom severity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option D: The findings cannot be interpreted without knowing whether every participant had identical symptom severity is inappropriate because randomization permits comparison between groups without requiring all participants to have identical baseline symptom severity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The findings cannot be interpreted without knowing whether every participant had identical symptom severity is inappropriate because randomization permits comparison between groups without requiring all participants to have identical baseline symptom severity."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The findings cannot be interpreted without knowing whether every participant had identical symptom severity is inappropriate because randomization permits comparison between groups without requiring all participants to have identical baseline symptom severity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The placebo response invalidates the observed treatment effect is inappropriate because a placebo response does not invalidate a trial; efficacy is evaluated by comparing the treatment and placebo groups."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The placebo response invalidates the observed treatment effect is inappropriate because a placebo response does not invalidate a trial; efficacy is evaluated by comparing the treatment and placebo groups."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The p values establish that the improvement was clinically important is inappropriate because statistical significance addresses compatibility with a null hypothesis; it does not by itself establish that an effect is large enough to be clinically important. Clinical importance requires the effect magnitude and clinical context."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The p values establish that the improvement was clinically important is inappropriate because statistical significance addresses compatibility with a null hypothesis; it does not by itself establish that an effect is large enough to be clinically important. Clinical importance requires the effect magnitude and clinical context."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The extract produced a 69-percentage-point treatment-attributable improvement according to patients is inappropriate because sixty-nine percent is the extract group\u0027s raw patient-reported response rate (276/400), not the benefit attributable to treatment. The absolute treatment-placebo difference is 69%-55%=14 percentage points."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The extract produced a 69-percentage-point treatment-attributable improvement according to patients is inappropriate because sixty-nine percent is the extract group\u0027s raw patient-reported response rate (276/400), not the benefit attributable to treatment. The absolute treatment-placebo difference is 69%-55%=14 percentage points."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The extract produced a 58-percentage-point treatment-attributable improvement according to clinicians is inappropriate because fifty-eight percent is the extract group\u0027s raw clinician-assessed response rate (232/400), not the treatment-attributable benefit. The absolute difference is 58%-42%=16 percentage points."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The extract produced a 58-percentage-point treatment-attributable improvement according to clinicians is inappropriate because fifty-eight percent is the extract group\u0027s raw clinician-assessed response rate (232/400), not the treatment-attributable benefit. The absolute difference is 58%-42%=16 percentage points."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The identical p values establish that the treatment effect was the same size for both outcomes is inappropriate because equal p-value reporting does not imply equal effect sizes. The observed absolute differences are 14 percentage points for patient reports and 16 percentage points for clinician ratings."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The identical p values establish that the treatment effect was the same size for both outcomes is inappropriate because equal p-value reporting does not imply equal effect sizes. The observed absolute differences are 14 percentage points for patient reports and 16 percentage points for clinician ratings."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No conclusion about either outcome can be drawn unless confidence intervals are provided is inappropriate because confidence intervals would improve assessment of precision, but the reported counts and p values already permit the conclusion that both treatment-placebo comparisons are statistically significant."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No conclusion about either outcome can be drawn unless confidence intervals are provided is inappropriate because confidence intervals would improve assessment of precision, but the reported counts and p values already permit the conclusion that both treatment-placebo comparisons are statistically significant."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Randomization cannot support an efficacy conclusion when the outcomes are based on subjective assessments is inappropriate because subjective outcomes can be valid trial endpoints. Randomized placebo-controlled allocation still permits treatment-placebo comparisons for each prespecified outcome."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Randomization cannot support an efficacy conclusion when the outcomes are based on subjective assessments is inappropriate because subjective outcomes can be valid trial endpoints. Randomized placebo-controlled allocation still permits treatment-placebo comparisons for each prespecified outcome."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The larger placebo response among patient reports proves that the patient-reported endpoint was biased is inappropriate because different placebo response rates across separately defined outcomes do not prove measurement bias. Patient and clinician assessments may use different definitions, thresholds, or scales."
            },
            {
              "id": "B",
              "text": "Option B: The extract was effective only when outcomes were reported by patients is inappropriate because clinician ratings also favored the extract, with improvement in 232 of 400 recipients versus 168 of 400 placebo recipients."
            },
            {
              "id": "C",
              "text": "Option C: The greater patient-reported response proves that patient ratings are more valid than clinician ratings is inappropriate because response percentages obtained using different assessment methods cannot establish that one method is more valid than the other."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The larger placebo response among patient reports proves that the patient-reported endpoint was biased is inappropriate because different placebo response rates across separately defined outcomes do not prove measurement bias. Patient and clinician assessments may use different definitions, thresholds, or scales."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i009-number-needed-to-treat",
      "expectedHashes": {
        "ranaze_step3_uat": "348d9687ec054f9b81f7431949a9560b1ff80828b714c9ac0672f7fc139ea712",
        "ranaze_step3_prd": "348d9687ec054f9b81f7431949a9560b1ff80828b714c9ac0672f7fc139ea712"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "8 is inappropriate because this does not equal the reciprocal of the observed 0.20 absolute benefit increase."
            },
            {
              "id": "B",
              "text": "Option C: This would correspond to an absolute benefit increase of 10%, rather than the observed 20%."
            },
            {
              "id": "C",
              "text": "Option D: This would correspond to an absolute benefit increase of 5%, rather than the observed 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "8 is inappropriate because this does not equal the reciprocal of the observed 0.20 absolute benefit increase."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This would correspond to an absolute benefit increase of 10%, rather than the observed 20%."
            },
            {
              "id": "B",
              "text": "Option B: 8 is inappropriate because this does not equal the reciprocal of the observed 0.20 absolute benefit increase."
            },
            {
              "id": "C",
              "text": "Option D: This would correspond to an absolute benefit increase of 5%, rather than the observed 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This would correspond to an absolute benefit increase of 10%, rather than the observed 20%."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This would correspond to an absolute benefit increase of 5%, rather than the observed 20%."
            },
            {
              "id": "B",
              "text": "Option B: 8 is inappropriate because this does not equal the reciprocal of the observed 0.20 absolute benefit increase."
            },
            {
              "id": "C",
              "text": "Option C: This would correspond to an absolute benefit increase of 10%, rather than the observed 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This would correspond to an absolute benefit increase of 5%, rather than the observed 20%."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "50 is inappropriate because this would correspond to an absolute benefit increase of 2%, which substantially understates the observed treatment effect."
            },
            {
              "id": "B",
              "text": "Option B: 8 is inappropriate because this does not equal the reciprocal of the observed 0.20 absolute benefit increase."
            },
            {
              "id": "C",
              "text": "Option C: This would correspond to an absolute benefit increase of 10%, rather than the observed 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "50 is inappropriate because this would correspond to an absolute benefit increase of 2%, which substantially understates the observed treatment effect."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Approximately 1.7 is the reciprocal of the program response rate (1/0.60), not the reciprocal of the absolute benefit increase."
            },
            {
              "id": "B",
              "text": "Option B: 8 is inappropriate because this does not equal the reciprocal of the observed 0.20 absolute benefit increase."
            },
            {
              "id": "C",
              "text": "Option C: This would correspond to an absolute benefit increase of 10%, rather than the observed 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Approximately 1.7 is the reciprocal of the program response rate (1/0.60), not the reciprocal of the absolute benefit increase."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "2 is inappropriate because two is obtained by taking the reciprocal of the 50% relative increase in response, but NNT is calculated from the absolute event-rate difference."
            },
            {
              "id": "B",
              "text": "Option B: 8 is inappropriate because this does not equal the reciprocal of the observed 0.20 absolute benefit increase."
            },
            {
              "id": "C",
              "text": "Option C: This would correspond to an absolute benefit increase of 10%, rather than the observed 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "2 is inappropriate because two is obtained by taking the reciprocal of the 50% relative increase in response, but NNT is calculated from the absolute event-rate difference."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A value of 2.5 is the reciprocal of the usual-care response rate (1/0.40), which is not the NNT formula."
            },
            {
              "id": "B",
              "text": "Option B: 8 is inappropriate because this does not equal the reciprocal of the observed 0.20 absolute benefit increase."
            },
            {
              "id": "C",
              "text": "Option C: This would correspond to an absolute benefit increase of 10%, rather than the observed 20%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A value of 2.5 is the reciprocal of the usual-care response rate (1/0.40), which is not the NNT formula."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i010-alcohol-and-hypertension",
      "expectedHashes": {
        "ranaze_step3_uat": "f1d6e3825236ad2d4748a4a7c6a7a993bff25479c5d1957c6c0c26b78e0432eb",
        "ranaze_step3_prd": "f1d6e3825236ad2d4748a4a7c6a7a993bff25479c5d1957c6c0c26b78e0432eb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
            },
            {
              "id": "B",
              "text": "Option C: Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
            },
            {
              "id": "C",
              "text": "Option D: Amlodipine and valsartan should not be administered together is inappropriate because a calcium channel blocker and an angiotensin receptor blocker can be used together for hypertension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
            },
            {
              "id": "B",
              "text": "Option B: His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
            },
            {
              "id": "C",
              "text": "Option D: Amlodipine and valsartan should not be administered together is inappropriate because a calcium channel blocker and an angiotensin receptor blocker can be used together for hypertension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amlodipine and valsartan should not be administered together is inappropriate because a calcium channel blocker and an angiotensin receptor blocker can be used together for hypertension."
            },
            {
              "id": "B",
              "text": "Option B: His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
            },
            {
              "id": "C",
              "text": "Option C: Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amlodipine and valsartan should not be administered together is inappropriate because a calcium channel blocker and an angiotensin receptor blocker can be used together for hypertension."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His normal creatinine excludes clinically important hypertension is inappropriate because normal kidney function does not negate an elevated blood pressure or its long-term cardiovascular risk."
            },
            {
              "id": "B",
              "text": "Option B: His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
            },
            {
              "id": "C",
              "text": "Option C: Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His normal creatinine excludes clinically important hypertension is inappropriate because normal kidney function does not negate an elevated blood pressure or its long-term cardiovascular risk."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Four servings of whiskey daily are within the recommended alcohol limit for a man with hypertension is inappropriate because four daily servings exceed the recommended limit of no more than two drinks per day for men who choose to drink; current cardiovascular guidance states that ideally alcohol should be avoided."
            },
            {
              "id": "B",
              "text": "Option B: His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
            },
            {
              "id": "C",
              "text": "Option C: Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Four servings of whiskey daily are within the recommended alcohol limit for a man with hypertension is inappropriate because four daily servings exceed the recommended limit of no more than two drinks per day for men who choose to drink; current cardiovascular guidance states that ideally alcohol should be avoided."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He has resistant hypertension and should undergo an extensive secondary-hypertension evaluation before modifiable lifestyle contributors are addressed is inappropriate because resistant hypertension generally requires uncontrolled pressure despite three appropriately selected drug classes, commonly including a diuretic, or control requiring four drugs. This patient takes two agents and has an obvious lifestyle contributor that should be addressed."
            },
            {
              "id": "B",
              "text": "Option B: His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
            },
            {
              "id": "C",
              "text": "Option C: Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He has resistant hypertension and should undergo an extensive secondary-hypertension evaluation before modifiable lifestyle contributors are addressed is inappropriate because resistant hypertension generally requires uncontrolled pressure despite three appropriately selected drug classes, commonly including a diuretic, or control requiring four drugs. This patient takes two agents and has an obvious lifestyle contributor that should be addressed."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reducing alcohol is unlikely to improve blood pressure because the alcohol is consumed as distilled spirits rather than beer or wine is inappropriate because ethanol can raise blood pressure regardless of whether it is consumed as liquor, beer, or wine. A standard serving of 80-proof spirits counts as an alcoholic drink."
            },
            {
              "id": "B",
              "text": "Option B: His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
            },
            {
              "id": "C",
              "text": "Option C: Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reducing alcohol is unlikely to improve blood pressure because the alcohol is consumed as distilled spirits rather than beer or wine is inappropriate because ethanol can raise blood pressure regardless of whether it is consumed as liquor, beer, or wine. A standard serving of 80-proof spirits counts as an alcoholic drink."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lifestyle factors can no longer influence blood pressure once two antihypertensive medications are being taken consistently is inappropriate because lifestyle measures remain part of hypertension treatment alongside medication. Excess alcohol can continue to elevate blood pressure despite adherence to pharmacotherapy."
            },
            {
              "id": "B",
              "text": "Option B: His blood pressure is adequately controlled because he has no symptoms is inappropriate because hypertension is usually asymptomatic; absence of symptoms does not indicate adequate control."
            },
            {
              "id": "C",
              "text": "Option C: Brisk walking should be stopped until his blood pressure normalizes is inappropriate because regular aerobic activity is beneficial for blood pressure and need not be stopped in this asymptomatic patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lifestyle factors can no longer influence blood pressure once two antihypertensive medications are being taken consistently is inappropriate because lifestyle measures remain part of hypertension treatment alongside medication. Excess alcohol can continue to elevate blood pressure despite adherence to pharmacotherapy."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i011-thiazide-sexual-dysfunction",
      "expectedHashes": {
        "ranaze_step3_uat": "dee3b390da51ec6a06e73e1836ae867b24afb9b5cbac1f136aee8ccc9fac50f4",
        "ranaze_step3_prd": "dee3b390da51ec6a06e73e1836ae867b24afb9b5cbac1f136aee8ccc9fac50f4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "ACE inhibitors are less commonly associated with sexual dysfunction than thiazide-type diuretics, and lisinopril was already being taken before chlorthalidone was added."
            },
            {
              "id": "B",
              "text": "Option C: His weekly alcohol consumption is inappropriate because one beer weekly is unlikely to cause persistent erectile dysfunction and loss of libido."
            },
            {
              "id": "C",
              "text": "Option D: The normal total testosterone concentration argues against androgen deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "ACE inhibitors are less commonly associated with sexual dysfunction than thiazide-type diuretics, and lisinopril was already being taken before chlorthalidone was added."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His weekly alcohol consumption is inappropriate because one beer weekly is unlikely to cause persistent erectile dysfunction and loss of libido."
            },
            {
              "id": "B",
              "text": "Option B: ACE inhibitors are less commonly associated with sexual dysfunction than thiazide-type diuretics, and lisinopril was already being taken before chlorthalidone was added."
            },
            {
              "id": "C",
              "text": "Option D: The normal total testosterone concentration argues against androgen deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His weekly alcohol consumption is inappropriate because one beer weekly is unlikely to cause persistent erectile dysfunction and loss of libido."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The normal total testosterone concentration argues against androgen deficiency."
            },
            {
              "id": "B",
              "text": "Option B: ACE inhibitors are less commonly associated with sexual dysfunction than thiazide-type diuretics, and lisinopril was already being taken before chlorthalidone was added."
            },
            {
              "id": "C",
              "text": "Option C: His weekly alcohol consumption is inappropriate because one beer weekly is unlikely to cause persistent erectile dysfunction and loss of libido."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The normal total testosterone concentration argues against androgen deficiency."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The normal fasting glucose concentration provides no evidence of diabetes mellitus."
            },
            {
              "id": "B",
              "text": "Option B: ACE inhibitors are less commonly associated with sexual dysfunction than thiazide-type diuretics, and lisinopril was already being taken before chlorthalidone was added."
            },
            {
              "id": "C",
              "text": "Option C: His weekly alcohol consumption is inappropriate because one beer weekly is unlikely to cause persistent erectile dysfunction and loss of libido."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The normal fasting glucose concentration provides no evidence of diabetes mellitus."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Major depressive disorder is inappropriate because depression can reduce libido and contribute to erectile dysfunction, but the stem explicitly states that he has no depressed mood. The temporal relationship to starting chlorthalidone is more compelling."
            },
            {
              "id": "B",
              "text": "Option B: ACE inhibitors are less commonly associated with sexual dysfunction than thiazide-type diuretics, and lisinopril was already being taken before chlorthalidone was added."
            },
            {
              "id": "C",
              "text": "Option C: His weekly alcohol consumption is inappropriate because one beer weekly is unlikely to cause persistent erectile dysfunction and loss of libido."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Major depressive disorder is inappropriate because depression can reduce libido and contribute to erectile dysfunction, but the stem explicitly states that he has no depressed mood. The temporal relationship to starting chlorthalidone is more compelling."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hypothyroidism can cause reduced libido and erectile dysfunction, but his thyroid-stimulating hormone concentration is normal at 2.1 mIU/L."
            },
            {
              "id": "B",
              "text": "Option B: ACE inhibitors are less commonly associated with sexual dysfunction than thiazide-type diuretics, and lisinopril was already being taken before chlorthalidone was added."
            },
            {
              "id": "C",
              "text": "Option C: His weekly alcohol consumption is inappropriate because one beer weekly is unlikely to cause persistent erectile dysfunction and loss of libido."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hypothyroidism can cause reduced libido and erectile dysfunction, but his thyroid-stimulating hormone concentration is normal at 2.1 mIU/L."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i013-neural-tube-defect-risk-calculation",
      "expectedHashes": {
        "ranaze_step3_uat": "8377f0c430dc9ab4fb37338a286427fefdec49ace147cc50adcff72a5ab19fa9",
        "ranaze_step3_prd": "8377f0c430dc9ab4fb37338a286427fefdec49ace147cc50adcff72a5ab19fa9"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Her two losses increase the untreated risk to 1.6 per 1000 is inappropriate because the supplied data assign an increased risk only after four unexplained losses; they do not support doubling risk after two losses."
            },
            {
              "id": "B",
              "text": "Option B: Her age increases the untreated risk above 0.8 per 1000 is inappropriate because the stated age-related increase begins after age 32 years, and the patient is 27 years old."
            },
            {
              "id": "C",
              "text": "Option C: Folic acid would reduce her risk to 0.6 per 1000 is inappropriate because a 75% reduction leaves 25%, not 75%, of the baseline risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Her two losses increase the untreated risk to 1.6 per 1000 is inappropriate because the supplied data assign an increased risk only after four unexplained losses; they do not support doubling risk after two losses."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Her age increases the untreated risk above 0.8 per 1000 is inappropriate because the stated age-related increase begins after age 32 years, and the patient is 27 years old."
            },
            {
              "id": "B",
              "text": "Option A: Her two losses increase the untreated risk to 1.6 per 1000 is inappropriate because the supplied data assign an increased risk only after four unexplained losses; they do not support doubling risk after two losses."
            },
            {
              "id": "C",
              "text": "Option C: Folic acid would reduce her risk to 0.6 per 1000 is inappropriate because a 75% reduction leaves 25%, not 75%, of the baseline risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Her age increases the untreated risk above 0.8 per 1000 is inappropriate because the stated age-related increase begins after age 32 years, and the patient is 27 years old."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Folic acid would reduce her risk to 0.6 per 1000 is inappropriate because a 75% reduction leaves 25%, not 75%, of the baseline risk."
            },
            {
              "id": "B",
              "text": "Option A: Her two losses increase the untreated risk to 1.6 per 1000 is inappropriate because the supplied data assign an increased risk only after four unexplained losses; they do not support doubling risk after two losses."
            },
            {
              "id": "C",
              "text": "Option B: Her age increases the untreated risk above 0.8 per 1000 is inappropriate because the stated age-related increase begins after age 32 years, and the patient is 27 years old."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Folic acid would reduce her risk to 0.6 per 1000 is inappropriate because a 75% reduction leaves 25%, not 75%, of the baseline risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The review does not provide enough information to estimate her risk is inappropriate because the review supplies a first-pregnancy baseline and a treatment effect, and neither specified risk modifier applies to this patient."
            },
            {
              "id": "B",
              "text": "Option A: Her two losses increase the untreated risk to 1.6 per 1000 is inappropriate because the supplied data assign an increased risk only after four unexplained losses; they do not support doubling risk after two losses."
            },
            {
              "id": "C",
              "text": "Option B: Her age increases the untreated risk above 0.8 per 1000 is inappropriate because the stated age-related increase begins after age 32 years, and the patient is 27 years old."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The review does not provide enough information to estimate her risk is inappropriate because the review supplies a first-pregnancy baseline and a treatment effect, and neither specified risk modifier applies to this patient."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Folic acid would subtract 0.75 per 1000, leaving a risk of 0.05 per 1000 is inappropriate because the stated 75% reduction is relative, not an absolute subtraction of 0.75 per 1000. It leaves 25% of 0.8 per 1000, or 0.2 per 1000."
            },
            {
              "id": "B",
              "text": "Option A: Her two losses increase the untreated risk to 1.6 per 1000 is inappropriate because the supplied data assign an increased risk only after four unexplained losses; they do not support doubling risk after two losses."
            },
            {
              "id": "C",
              "text": "Option B: Her age increases the untreated risk above 0.8 per 1000 is inappropriate because the stated age-related increase begins after age 32 years, and the patient is 27 years old."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Folic acid would subtract 0.75 per 1000, leaving a risk of 0.05 per 1000 is inappropriate because the stated 75% reduction is relative, not an absolute subtraction of 0.75 per 1000. It leaves 25% of 0.8 per 1000, or 0.2 per 1000."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "With folic acid, her risk would remain 0.8 per 1000 is inappropriate because this retains the correct untreated baseline but fails to apply the stated 75% relative reduction from folic acid."
            },
            {
              "id": "B",
              "text": "Option A: Her two losses increase the untreated risk to 1.6 per 1000 is inappropriate because the supplied data assign an increased risk only after four unexplained losses; they do not support doubling risk after two losses."
            },
            {
              "id": "C",
              "text": "Option B: Her age increases the untreated risk above 0.8 per 1000 is inappropriate because the stated age-related increase begins after age 32 years, and the patient is 27 years old."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "With folic acid, her risk would remain 0.8 per 1000 is inappropriate because this retains the correct untreated baseline but fails to apply the stated 75% relative reduction from folic acid."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i018-ppi-hypergastrinemia",
      "expectedHashes": {
        "ranaze_step3_uat": "02968e32653069e544e83704e180177381efc66b7c25b16d61290c346073c55e",
        "ranaze_step3_prd": "02968e32653069e544e83704e180177381efc66b7c25b16d61290c346073c55e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
            },
            {
              "id": "B",
              "text": "Option B: Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
            },
            {
              "id": "C",
              "text": "Option C: Perform a secretin stimulation test immediately is inappropriate because secretin stimulation can help evaluate equivocal hypergastrinemia after acid-mediated and medication-related causes have been assessed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
            },
            {
              "id": "B",
              "text": "Option A: Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
            },
            {
              "id": "C",
              "text": "Option C: Perform a secretin stimulation test immediately is inappropriate because secretin stimulation can help evaluate equivocal hypergastrinemia after acid-mediated and medication-related causes have been assessed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a secretin stimulation test immediately is inappropriate because secretin stimulation can help evaluate equivocal hypergastrinemia after acid-mediated and medication-related causes have been assessed."
            },
            {
              "id": "B",
              "text": "Option A: Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
            },
            {
              "id": "C",
              "text": "Option B: Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a secretin stimulation test immediately is inappropriate because secretin stimulation can help evaluate equivocal hypergastrinemia after acid-mediated and medication-related causes have been assessed."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat upper endoscopy immediately is inappropriate because immediate endoscopy is not required in the absence of alarm features, and it would not determine whether pantoprazole caused the biochemical abnormality."
            },
            {
              "id": "B",
              "text": "Option A: Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
            },
            {
              "id": "C",
              "text": "Option B: Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat upper endoscopy immediately is inappropriate because immediate endoscopy is not required in the absence of alarm features, and it would not determine whether pantoprazole caused the biochemical abnormality."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat the fasting gastrin concentration while continuing pantoprazole is inappropriate because repeating gastrin without addressing pantoprazole preserves the same medication-related confounding. PPIs suppress acid and can elevate gastrin; the repeat test should follow supervised withdrawal or substitution and should be interpreted with gastric acidity."
            },
            {
              "id": "B",
              "text": "Option A: Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
            },
            {
              "id": "C",
              "text": "Option B: Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat the fasting gastrin concentration while continuing pantoprazole is inappropriate because repeating gastrin without addressing pantoprazole preserves the same medication-related confounding. PPIs suppress acid and can elevate gastrin; the repeat test should follow supervised withdrawal or substitution and should be interpreted with gastric acidity."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure gastric pH while she continues pantoprazole is inappropriate because pantoprazole deliberately raises gastric pH, so measuring pH while treatment continues cannot determine whether the patient has inappropriate hypergastrinemia in the presence of endogenous gastric acid secretion. Medication adjustment and repeat fasting gastrin with pH measurement must be coordinated."
            },
            {
              "id": "B",
              "text": "Option A: Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
            },
            {
              "id": "C",
              "text": "Option B: Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure gastric pH while she continues pantoprazole is inappropriate because pantoprazole deliberately raises gastric pH, so measuring pH while treatment continues cannot determine whether the patient has inappropriate hypergastrinemia in the presence of endogenous gastric acid secretion. Medication adjustment and repeat fasting gastrin with pH measurement must be coordinated."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure anti\u00E2\u20AC\u201Cparietal cell and anti\u00E2\u20AC\u201Cintrinsic factor antibodies is inappropriate because autoimmune atrophic gastritis is a cause of hypergastrinemia, but antibody testing is not the first step when a clear medication-related cause remains active. Gastrin should first be reassessed after supervised PPI withdrawal together with gastric pH."
            },
            {
              "id": "B",
              "text": "Option A: Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
            },
            {
              "id": "C",
              "text": "Option B: Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure anti\u00E2\u20AC\u201Cparietal cell and anti\u00E2\u20AC\u201Cintrinsic factor antibodies is inappropriate because autoimmune atrophic gastritis is a cause of hypergastrinemia, but antibody testing is not the first step when a clear medication-related cause remains active. Gastrin should first be reassessed after supervised PPI withdrawal together with gastric pH."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure serum chromogranin A while she continues pantoprazole is inappropriate because chromogranin A is not an appropriate next test because proton pump inhibitors can elevate both gastrin and chromogranin A through acid suppression and enterochromaffin-like cell stimulation. Measuring it during ongoing pantoprazole therapy could produce a false-positive neuroendocrine-tumor signal without resolving the medication confounder."
            },
            {
              "id": "B",
              "text": "Option A: Obtain contrast-enhanced CT of the abdomen is inappropriate because cross-sectional imaging is used to localize a tumor after biochemical evidence supports gastrinoma; it is premature when medication-induced hypergastrinemia has not been excluded."
            },
            {
              "id": "C",
              "text": "Option B: Perform somatostatin-receptor imaging is inappropriate because somatostatin-receptor imaging can localize neuroendocrine tumors but should not precede biochemical confirmation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure serum chromogranin A while she continues pantoprazole is inappropriate because chromogranin A is not an appropriate next test because proton pump inhibitors can elevate both gastrin and chromogranin A through acid suppression and enterochromaffin-like cell stimulation. Measuring it during ongoing pantoprazole therapy could produce a false-positive neuroendocrine-tumor signal without resolving the medication confounder."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i019-external-validity",
      "expectedHashes": {
        "ranaze_step3_uat": "a7779db0289619dca26e2b304c4c2dd19c3fe3660a22ce04ceb488e9744a6acf",
        "ranaze_step3_prd": "a7779db0289619dca26e2b304c4c2dd19c3fe3660a22ce04ceb488e9744a6acf"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
            },
            {
              "id": "B",
              "text": "Option B: Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
            },
            {
              "id": "C",
              "text": "Option C: Whether the proposed tests are expensive is inappropriate because cost is relevant to implementation and resource use, but population comparability is the primary concern when generalizing the study\u0027s findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
            },
            {
              "id": "B",
              "text": "Option A: Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
            },
            {
              "id": "C",
              "text": "Option C: Whether the proposed tests are expensive is inappropriate because cost is relevant to implementation and resource use, but population comparability is the primary concern when generalizing the study\u0027s findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the proposed tests are expensive is inappropriate because cost is relevant to implementation and resource use, but population comparability is the primary concern when generalizing the study\u0027s findings."
            },
            {
              "id": "B",
              "text": "Option A: Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
            },
            {
              "id": "C",
              "text": "Option B: Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the proposed tests are expensive is inappropriate because cost is relevant to implementation and resource use, but population comparability is the primary concern when generalizing the study\u0027s findings."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the investigators used a prospective rather than retrospective design is inappropriate because study design contributes to internal validity, which the physician has already assessed; the remaining key issue is external validity."
            },
            {
              "id": "B",
              "text": "Option A: Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
            },
            {
              "id": "C",
              "text": "Option B: Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the investigators used a prospective rather than retrospective design is inappropriate because study design contributes to internal validity, which the physician has already assessed; the remaining key issue is external validity."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the study enrolled enough participants to detect uncommon surgically correctable causes is inappropriate because sample size affects precision and the ability to characterize uncommon outcomes, but the physician has already found the methods and analysis sound. The central remaining issue is whether prevalence and recommendations from a specialty referral sample apply to community patients."
            },
            {
              "id": "B",
              "text": "Option A: Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
            },
            {
              "id": "C",
              "text": "Option B: Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the study enrolled enough participants to detect uncommon surgically correctable causes is inappropriate because sample size affects precision and the ability to characterize uncommon outcomes, but the physician has already found the methods and analysis sound. The central remaining issue is whether prevalence and recommendations from a specialty referral sample apply to community patients."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether referred adults were enrolled consecutively is inappropriate because consecutive enrollment can reduce selection bias within the referral-center source population, but it cannot make that specialty population representative of adults with newly recognized hypertension in a community clinic."
            },
            {
              "id": "B",
              "text": "Option A: Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
            },
            {
              "id": "C",
              "text": "Option B: Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether referred adults were enrolled consecutively is inappropriate because consecutive enrollment can reduce selection bias within the referral-center source population, but it cannot make that specialty population representative of adults with newly recognized hypertension in a community clinic."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the analysis adjusted for age and sex is inappropriate because adjustment can address measured confounding within the sampled population. It cannot by itself transport a referral-enriched prevalence or universal-testing strategy to a clinically different target population."
            },
            {
              "id": "B",
              "text": "Option A: Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
            },
            {
              "id": "C",
              "text": "Option B: Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the analysis adjusted for age and sex is inappropriate because adjustment can address measured confounding within the sampled population. It cannot by itself transport a referral-enriched prevalence or universal-testing strategy to a clinically different target population."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the article underwent peer review before publication is inappropriate because peer review is not a substitute for the clinician\u0027s appraisal of validity and applicability. The methods are already deemed sound; population and setting comparability remain decisive."
            },
            {
              "id": "B",
              "text": "Option A: Whether the community clinic already owns the necessary imaging equipment is inappropriate because local availability affects feasibility but does not establish whether the study\u0027s recommendation is clinically applicable to community patients."
            },
            {
              "id": "C",
              "text": "Option B: Whether any study participants experienced surgical complications is inappropriate because surgical harms are relevant to the overall balance of benefits and risks, but they do not resolve whether the referral population represents this physician\u0027s patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the article underwent peer review before publication is inappropriate because peer review is not a substitute for the clinician\u0027s appraisal of validity and applicability. The methods are already deemed sound; population and setting comparability remain decisive."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i021-cruciate-ligament-disruption",
      "expectedHashes": {
        "ranaze_step3_uat": "999e04c5fe3317c4082e1d6a5fc7d67e5219412d66d058cc4284c7b395076fce",
        "ranaze_step3_prd": "999e04c5fe3317c4082e1d6a5fc7d67e5219412d66d058cc4284c7b395076fce"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "B",
              "text": "Option C: Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            },
            {
              "id": "C",
              "text": "Option D: An isolated medial collateral ligament tear produces valgus laxity rather than excessive anterior and posterior translation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            },
            {
              "id": "B",
              "text": "Option B: Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "C",
              "text": "Option D: An isolated medial collateral ligament tear produces valgus laxity rather than excessive anterior and posterior translation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An isolated medial collateral ligament tear produces valgus laxity rather than excessive anterior and posterior translation."
            },
            {
              "id": "B",
              "text": "Option B: Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "C",
              "text": "Option C: Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An isolated medial collateral ligament tear produces valgus laxity rather than excessive anterior and posterior translation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isolated meniscal tear is inappropriate because a meniscal tear may cause joint-line pain, locking, or clicking but does not cause gross multidirectional instability."
            },
            {
              "id": "B",
              "text": "Option B: Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "C",
              "text": "Option C: Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isolated meniscal tear is inappropriate because a meniscal tear may cause joint-line pain, locking, or clicking but does not cause gross multidirectional instability."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isolated anterior cruciate ligament tear is inappropriate because an isolated ACL tear causes excessive anterior tibial translation, but the pronounced posterior translation in this patient requires concomitant PCL disruption."
            },
            {
              "id": "B",
              "text": "Option B: Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "C",
              "text": "Option C: Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isolated anterior cruciate ligament tear is inappropriate because an isolated ACL tear causes excessive anterior tibial translation, but the pronounced posterior translation in this patient requires concomitant PCL disruption."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isolated posterior cruciate ligament tear is inappropriate because an isolated PCL tear causes excessive posterior tibial translation. It cannot account for the excessive anterior translation demonstrated under analgesia."
            },
            {
              "id": "B",
              "text": "Option B: Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "C",
              "text": "Option C: Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isolated posterior cruciate ligament tear is inappropriate because an isolated PCL tear causes excessive posterior tibial translation. It cannot account for the excessive anterior translation demonstrated under analgesia."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Combined anterior cruciate and medial collateral ligament disruption is inappropriate because combined ACL and MCL injury would produce anterior translation plus valgus laxity. This patient instead has little valgus laxity and marked translation in both sagittal directions."
            },
            {
              "id": "B",
              "text": "Option B: Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "C",
              "text": "Option C: Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Combined anterior cruciate and medial collateral ligament disruption is inappropriate because combined ACL and MCL injury would produce anterior translation plus valgus laxity. This patient instead has little valgus laxity and marked translation in both sagittal directions."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Posterolateral corner disruption is inappropriate because posterolateral corner injury produces varus and external-rotation instability. Little additional varus laxity and marked anterior-posterior translation localize the principal disruption to both cruciate ligaments."
            },
            {
              "id": "B",
              "text": "Option B: Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "C",
              "text": "Option C: Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Posterolateral corner disruption is inappropriate because posterolateral corner injury produces varus and external-rotation instability. Little additional varus laxity and marked anterior-posterior translation localize the principal disruption to both cruciate ligaments."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A tibial plateau fracture can cause pain, hemarthrosis, and impaired weight bearing, but it does not selectively produce marked anterior and posterior tibial translation. Witnessed tibiofemoral displacement followed by spontaneous reduction indicates a multiligament knee dislocation."
            },
            {
              "id": "B",
              "text": "Option B: Gastrocnemius muscle rupture is inappropriate because a gastrocnemius rupture causes posterior calf pain, swelling, and weakness but does not cause anterior and posterior tibial instability."
            },
            {
              "id": "C",
              "text": "Option C: Patellar tendon rupture disrupts the knee extensor mechanism and prevents a straight-leg raise, which remains intact here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A tibial plateau fracture can cause pain, hemarthrosis, and impaired weight bearing, but it does not selectively produce marked anterior and posterior tibial translation. Witnessed tibiofemoral displacement followed by spontaneous reduction indicates a multiligament knee dislocation."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i025-nonjudgmental-weight-interview",
      "expectedHashes": {
        "ranaze_step3_uat": "2c2c190b377d5ff648b73c9a50ba926739898b6a09e2cfbbc6890b3797f0fc19",
        "ranaze_step3_prd": "2c2c190b377d5ff648b73c9a50ba926739898b6a09e2cfbbc6890b3797f0fc19"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "B",
              "text": "Option B: \u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            },
            {
              "id": "C",
              "text": "Option D: \u0022Why have your previous attempts to control your weight failed?\u0022 is inappropriate because asking why the patient has failed is judgmental and presupposes that prior outcomes resulted from a personal deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            },
            {
              "id": "B",
              "text": "Option A: \u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "C",
              "text": "Option D: \u0022Why have your previous attempts to control your weight failed?\u0022 is inappropriate because asking why the patient has failed is judgmental and presupposes that prior outcomes resulted from a personal deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Why have your previous attempts to control your weight failed?\u0022 is inappropriate because asking why the patient has failed is judgmental and presupposes that prior outcomes resulted from a personal deficiency."
            },
            {
              "id": "B",
              "text": "Option A: \u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Why have your previous attempts to control your weight failed?\u0022 is inappropriate because asking why the patient has failed is judgmental and presupposes that prior outcomes resulted from a personal deficiency."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Your eating habits have caused you to develop diabetes.\u0022 is inappropriate because this statement assigns blame and oversimplifies the multifactorial relationship between obesity and type 2 diabetes."
            },
            {
              "id": "B",
              "text": "Option A: \u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Your eating habits have caused you to develop diabetes.\u0022 is inappropriate because this statement assigns blame and oversimplifies the multifactorial relationship between obesity and type 2 diabetes."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Let\u0027s begin by setting a goal for you to lose 10% of your body weight.\u0022 is inappropriate because collaborative goal setting may be useful later, but immediately prescribing a target bypasses the patient\u0027s expression of shame and the need to explore causes, readiness, and preferences."
            },
            {
              "id": "B",
              "text": "Option A: \u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Let\u0027s begin by setting a goal for you to lose 10% of your body weight.\u0022 is inappropriate because collaborative goal setting may be useful later, but immediately prescribing a target bypasses the patient\u0027s expression of shame and the need to explore causes, readiness, and preferences."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Have you been binge eating during these past 3 months?\u0022 is inappropriate because binge-eating disorder may warrant assessment, but a leading diagnostic question is too narrow as the first response and may reinforce shame. Open-ended exploration should precede focused screening."
            },
            {
              "id": "B",
              "text": "Option A: \u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Have you been binge eating during these past 3 months?\u0022 is inappropriate because binge-eating disorder may warrant assessment, but a leading diagnostic question is too narrow as the first response and may reinforce shame. Open-ended exploration should precede focused screening."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Don\u0027t be so hard on yourself; almost everyone has trouble controlling weight.\u0022 is inappropriate because the statement is intended as reassurance but minimizes the patient\u0027s distress and frames weight as a problem of control. A curious, nonjudgmental response better facilitates disclosure."
            },
            {
              "id": "B",
              "text": "Option A: \u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Don\u0027t be so hard on yourself; almost everyone has trouble controlling weight.\u0022 is inappropriate because the statement is intended as reassurance but minimizes the patient\u0027s distress and frames weight as a problem of control. A curious, nonjudgmental response better facilitates disclosure."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Before discussing your weight, we need to repeat your glucose test to confirm diabetes.\u0022 is inappropriate because the patient has classic hyperglycemic symptoms and a random plasma glucose of 318 mg/dL, but this response also ignores her immediate self-blame. The initial conversational response should address the cue and explore context rather than defer it."
            },
            {
              "id": "B",
              "text": "Option A: \u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Before discussing your weight, we need to repeat your glucose test to confirm diabetes.\u0022 is inappropriate because the patient has classic hyperglycemic symptoms and a random plasma glucose of 318 mg/dL, but this response also ignores her immediate self-blame. The initial conversational response should address the cue and explore context rather than defer it."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Would you start recording everything you eat in a food diary?\u0022 is inappropriate because self-monitoring can be part of a later treatment plan, but assigning it immediately assumes diet is the relevant cause and skips open-ended assessment of medical, psychological, and social factors."
            },
            {
              "id": "B",
              "text": "Option A: \u0022You need to be more disciplined about following a diet.\u0022 is inappropriate because this response characterizes obesity as a failure of discipline and is likely to increase shame rather than elicit useful information."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has cold intolerance contributed to your recent weight gain?\u0022 is inappropriate because cold intolerance may be relevant during a directed medical review, but immediately narrowing the discussion to one symptom misses the opportunity to explore the patient\u0027s broader circumstances."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Would you start recording everything you eat in a food diary?\u0022 is inappropriate because self-monitoring can be part of a later treatment plan, but assigning it immediately assumes diet is the relevant cause and skips open-ended assessment of medical, psychological, and social factors."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i027-septic-shock-vasodilation",
      "expectedHashes": {
        "ranaze_step3_uat": "d6f7269f1e75209e57b8d572818717fb9aebda8d363ecd1d262f565940fd8305",
        "ranaze_step3_prd": "d6f7269f1e75209e57b8d572818717fb9aebda8d363ecd1d262f565940fd8305"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute obstruction of left ventricular outflow is inappropriate because left ventricular outflow obstruction causes cardiogenic hypotension and would not be expected from this febrile infectious presentation with low filling pressure."
            },
            {
              "id": "B",
              "text": "Option B: Marked elevation of pulmonary vascular resistance is inappropriate because pulmonary vascular resistance can rise in severe pulmonary disease, but this does not account for the distributive shock pattern caused by pneumonia and systemic infection."
            },
            {
              "id": "C",
              "text": "Option C: Critical limitation of airflow through the bronchi is inappropriate because airflow obstruction explains respiratory symptoms in emphysema but does not principally cause profound hypotension with fever, consolidation, and low filling pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute obstruction of left ventricular outflow is inappropriate because left ventricular outflow obstruction causes cardiogenic hypotension and would not be expected from this febrile infectious presentation with low filling pressure."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Marked elevation of pulmonary vascular resistance is inappropriate because pulmonary vascular resistance can rise in severe pulmonary disease, but this does not account for the distributive shock pattern caused by pneumonia and systemic infection."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of left ventricular outflow is inappropriate because left ventricular outflow obstruction causes cardiogenic hypotension and would not be expected from this febrile infectious presentation with low filling pressure."
            },
            {
              "id": "C",
              "text": "Option C: Critical limitation of airflow through the bronchi is inappropriate because airflow obstruction explains respiratory symptoms in emphysema but does not principally cause profound hypotension with fever, consolidation, and low filling pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Marked elevation of pulmonary vascular resistance is inappropriate because pulmonary vascular resistance can rise in severe pulmonary disease, but this does not account for the distributive shock pattern caused by pneumonia and systemic infection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Critical limitation of airflow through the bronchi is inappropriate because airflow obstruction explains respiratory symptoms in emphysema but does not principally cause profound hypotension with fever, consolidation, and low filling pressure."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of left ventricular outflow is inappropriate because left ventricular outflow obstruction causes cardiogenic hypotension and would not be expected from this febrile infectious presentation with low filling pressure."
            },
            {
              "id": "C",
              "text": "Option B: Marked elevation of pulmonary vascular resistance is inappropriate because pulmonary vascular resistance can rise in severe pulmonary disease, but this does not account for the distributive shock pattern caused by pneumonia and systemic infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Critical limitation of airflow through the bronchi is inappropriate because airflow obstruction explains respiratory symptoms in emphysema but does not principally cause profound hypotension with fever, consolidation, and low filling pressure."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Primary depression of myocardial contractility is inappropriate because sepsis can eventually impair myocardial function, but the defining early hemodynamic disturbance is reduced systemic vascular resistance rather than primary pump failure."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of left ventricular outflow is inappropriate because left ventricular outflow obstruction causes cardiogenic hypotension and would not be expected from this febrile infectious presentation with low filling pressure."
            },
            {
              "id": "C",
              "text": "Option B: Marked elevation of pulmonary vascular resistance is inappropriate because pulmonary vascular resistance can rise in severe pulmonary disease, but this does not account for the distributive shock pattern caused by pneumonia and systemic infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Primary depression of myocardial contractility is inappropriate because sepsis can eventually impair myocardial function, but the defining early hemodynamic disturbance is reduced systemic vascular resistance rather than primary pump failure."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Marked systemic arteriolar constriction from endogenous catecholamine release is inappropriate because systemic arteriolar constriction would raise systemic vascular resistance and help defend arterial pressure. Septic shock instead initially causes arterial and arteriolar dilation with reduced peripheral resistance."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of left ventricular outflow is inappropriate because left ventricular outflow obstruction causes cardiogenic hypotension and would not be expected from this febrile infectious presentation with low filling pressure."
            },
            {
              "id": "C",
              "text": "Option B: Marked elevation of pulmonary vascular resistance is inappropriate because pulmonary vascular resistance can rise in severe pulmonary disease, but this does not account for the distributive shock pattern caused by pneumonia and systemic infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Marked systemic arteriolar constriction from endogenous catecholamine release is inappropriate because systemic arteriolar constriction would raise systemic vascular resistance and help defend arterial pressure. Septic shock instead initially causes arterial and arteriolar dilation with reduced peripheral resistance."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i030-nonjudgmental-maternal-communication",
      "expectedHashes": {
        "ranaze_step3_uat": "ea8ffe37c2a24abffaa615545506c2915356f4c939f1431401c1a0c7936770c8",
        "ranaze_step3_prd": "ea8ffe37c2a24abffaa615545506c2915356f4c939f1431401c1a0c7936770c8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Because methamphetamine was detected, I am required to report you immediately. is inappropriate because opening with a threat of reporting is punitive, undermines trust, and precedes an appropriate neutral discussion of the findings and local reporting requirements."
            },
            {
              "id": "B",
              "text": "Option B: You should have been honest when you were asked about substance use. is inappropriate because accusatory language is likely to provoke defensiveness and interfere with gathering clinically important information."
            },
            {
              "id": "C",
              "text": "Option C: Your baby is addicted to methamphetamine and will require prolonged treatment. is inappropriate because neonatal irritability after stimulant exposure does not establish addiction or predict a need for prolonged treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Because methamphetamine was detected, I am required to report you immediately. is inappropriate because opening with a threat of reporting is punitive, undermines trust, and precedes an appropriate neutral discussion of the findings and local reporting requirements."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "You should have been honest when you were asked about substance use. is inappropriate because accusatory language is likely to provoke defensiveness and interfere with gathering clinically important information."
            },
            {
              "id": "B",
              "text": "Option A: Because methamphetamine was detected, I am required to report you immediately. is inappropriate because opening with a threat of reporting is punitive, undermines trust, and precedes an appropriate neutral discussion of the findings and local reporting requirements."
            },
            {
              "id": "C",
              "text": "Option C: Your baby is addicted to methamphetamine and will require prolonged treatment. is inappropriate because neonatal irritability after stimulant exposure does not establish addiction or predict a need for prolonged treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "You should have been honest when you were asked about substance use. is inappropriate because accusatory language is likely to provoke defensiveness and interfere with gathering clinically important information."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Your baby is addicted to methamphetamine and will require prolonged treatment. is inappropriate because neonatal irritability after stimulant exposure does not establish addiction or predict a need for prolonged treatment."
            },
            {
              "id": "B",
              "text": "Option A: Because methamphetamine was detected, I am required to report you immediately. is inappropriate because opening with a threat of reporting is punitive, undermines trust, and precedes an appropriate neutral discussion of the findings and local reporting requirements."
            },
            {
              "id": "C",
              "text": "Option B: You should have been honest when you were asked about substance use. is inappropriate because accusatory language is likely to provoke defensiveness and interfere with gathering clinically important information."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Your baby is addicted to methamphetamine and will require prolonged treatment. is inappropriate because neonatal irritability after stimulant exposure does not establish addiction or predict a need for prolonged treatment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anything you tell me about substance use will remain completely confidential. is inappropriate because the physician should not promise absolute confidentiality because disclosure may be required under applicable child-safety laws."
            },
            {
              "id": "B",
              "text": "Option A: Because methamphetamine was detected, I am required to report you immediately. is inappropriate because opening with a threat of reporting is punitive, undermines trust, and precedes an appropriate neutral discussion of the findings and local reporting requirements."
            },
            {
              "id": "C",
              "text": "Option B: You should have been honest when you were asked about substance use. is inappropriate because accusatory language is likely to provoke defensiveness and interfere with gathering clinically important information."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anything you tell me about substance use will remain completely confidential. is inappropriate because the physician should not promise absolute confidentiality because disclosure may be required under applicable child-safety laws."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The urine test was positive for methamphetamine. How often do you use it? is inappropriate because immediately announcing the result and presuming recurrent use is less appropriate than first explaining the objective neonatal findings and why testing was performed. The physician can then disclose the result and invite a nonjudgmental history."
            },
            {
              "id": "B",
              "text": "Option A: Because methamphetamine was detected, I am required to report you immediately. is inappropriate because opening with a threat of reporting is punitive, undermines trust, and precedes an appropriate neutral discussion of the findings and local reporting requirements."
            },
            {
              "id": "C",
              "text": "Option B: You should have been honest when you were asked about substance use. is inappropriate because accusatory language is likely to provoke defensiveness and interfere with gathering clinically important information."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The urine test was positive for methamphetamine. How often do you use it? is inappropriate because immediately announcing the result and presuming recurrent use is less appropriate than first explaining the objective neonatal findings and why testing was performed. The physician can then disclose the result and invite a nonjudgmental history."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Your baby\u0027s vital signs and glucose are reassuring, so there is no immediate cause for concern. is inappropriate because normal oxygenation, temperature, and glucose do not negate the infant\u0027s tremulousness, irritability, feeding-related difficulty settling, or positive toxicology result. This statement provides false reassurance and fails to explain the evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Because methamphetamine was detected, I am required to report you immediately. is inappropriate because opening with a threat of reporting is punitive, undermines trust, and precedes an appropriate neutral discussion of the findings and local reporting requirements."
            },
            {
              "id": "C",
              "text": "Option B: You should have been honest when you were asked about substance use. is inappropriate because accusatory language is likely to provoke defensiveness and interfere with gathering clinically important information."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Your baby\u0027s vital signs and glucose are reassuring, so there is no immediate cause for concern. is inappropriate because normal oxygenation, temperature, and glucose do not negate the infant\u0027s tremulousness, irritability, feeding-related difficulty settling, or positive toxicology result. This statement provides false reassurance and fails to explain the evaluation."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i031-multiple-sclerosis-internuclear-ophthalmoplegia",
      "expectedHashes": {
        "ranaze_step3_uat": "816859336e559f9b5ef45c715b5ffd8bf176b86151ec03d6a040ea0c92d68c6b",
        "ranaze_step3_prd": "816859336e559f9b5ef45c715b5ffd8bf176b86151ec03d6a040ea0c92d68c6b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
            },
            {
              "id": "B",
              "text": "Option B: Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
            },
            {
              "id": "C",
              "text": "Option D: Posterior circulation ischemic stroke is inappropriate because a stroke typically causes a sudden focal deficit corresponding to one vascular territory rather than episodes affecting distinct central nervous system sites over several years."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
            },
            {
              "id": "B",
              "text": "Option A: Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
            },
            {
              "id": "C",
              "text": "Option D: Posterior circulation ischemic stroke is inappropriate because a stroke typically causes a sudden focal deficit corresponding to one vascular territory rather than episodes affecting distinct central nervous system sites over several years."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Posterior circulation ischemic stroke is inappropriate because a stroke typically causes a sudden focal deficit corresponding to one vascular territory rather than episodes affecting distinct central nervous system sites over several years."
            },
            {
              "id": "B",
              "text": "Option A: Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
            },
            {
              "id": "C",
              "text": "Option B: Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Posterior circulation ischemic stroke is inappropriate because a stroke typically causes a sudden focal deficit corresponding to one vascular territory rather than episodes affecting distinct central nervous system sites over several years."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Functional neurologic symptom disorder is inappropriate because the reproducible ocular motor abnormality, reduced vibration sensation, and prior objective visual dysfunction support an organic neurologic disorder."
            },
            {
              "id": "B",
              "text": "Option A: Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
            },
            {
              "id": "C",
              "text": "Option B: Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Functional neurologic symptom disorder is inappropriate because the reproducible ocular motor abnormality, reduced vibration sensation, and prior objective visual dysfunction support an organic neurologic disorder."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vitamin B12 deficiency can cause impaired vibration sensation and gait dysfunction, but it does not adequately explain a resolved episode of painful monocular optic neuritis followed years later by bilateral internuclear ophthalmoplegia and bladder symptoms."
            },
            {
              "id": "B",
              "text": "Option A: Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
            },
            {
              "id": "C",
              "text": "Option B: Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vitamin B12 deficiency can cause impaired vibration sensation and gait dysfunction, but it does not adequately explain a resolved episode of painful monocular optic neuritis followed years later by bilateral internuclear ophthalmoplegia and bladder symptoms."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute disseminated encephalomyelitis is generally an acute, monophasic, multifocal demyelinating illness and commonly includes encephalopathy. Distinct attacks four years apart without encephalopathy favor relapsing multiple sclerosis."
            },
            {
              "id": "B",
              "text": "Option A: Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
            },
            {
              "id": "C",
              "text": "Option B: Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute disseminated encephalomyelitis is generally an acute, monophasic, multifocal demyelinating illness and commonly includes encephalopathy. Distinct attacks four years apart without encephalopathy favor relapsing multiple sclerosis."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A brainstem glioma could produce an ocular-motor deficit and gait dysfunction, but one focal structural lesion would not explain a separate painful optic-neuritis episode four years earlier, bilateral distal sensory loss, and relapsing dissemination across CNS locations."
            },
            {
              "id": "B",
              "text": "Option A: Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
            },
            {
              "id": "C",
              "text": "Option B: Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A brainstem glioma could produce an ocular-motor deficit and gait dysfunction, but one focal structural lesion would not explain a separate painful optic-neuritis episode four years earlier, bilateral distal sensory loss, and relapsing dissemination across CNS locations."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Migraine with brainstem aura can cause transient diplopia and ataxia, but aura does not explain persistent objective internuclear ophthalmoplegia, reduced vibration sensation, bladder symptoms, or prior optic-nerve dysfunction with reduced acuity and color perception."
            },
            {
              "id": "B",
              "text": "Option A: Myasthenia gravis can cause fluctuating diplopia but does not explain optic neuritis, sensory loss, bladder symptoms, or internuclear ophthalmoplegia."
            },
            {
              "id": "C",
              "text": "Option B: Wernicke encephalopathy can cause ophthalmoplegia and ataxia, but the separated neurologic episodes and prior painful monocular visual loss favor central demyelination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Migraine with brainstem aura can cause transient diplopia and ataxia, but aura does not explain persistent objective internuclear ophthalmoplegia, reduced vibration sensation, bladder symptoms, or prior optic-nerve dysfunction with reduced acuity and color perception."
        }
      }
    },
    {
      "externalId": "nbme5-s2-i032-randomized-trial-interpretation",
      "expectedHashes": {
        "ranaze_step3_uat": "c4cd89f1ef841a1509ee90f0e9b4f292d6def388497adee020225be388e818b7",
        "ranaze_step3_prd": "c4cd89f1ef841a1509ee90f0e9b4f292d6def388497adee020225be388e818b7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "B",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            },
            {
              "id": "C",
              "text": "Option C: Anticoagulant P has been proven safer because its observed bleeding rate is lower. is inappropriate because the bleeding p value is 0.48, so the numerical difference does not establish greater safety."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option C: Anticoagulant P has been proven safer because its observed bleeding rate is lower. is inappropriate because the bleeding p value is 0.48, so the numerical difference does not establish greater safety."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anticoagulant P has been proven safer because its observed bleeding rate is lower. is inappropriate because the bleeding p value is 0.48, so the numerical difference does not establish greater safety."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anticoagulant P has been proven safer because its observed bleeding rate is lower. is inappropriate because the bleeding p value is 0.48, so the numerical difference does not establish greater safety."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The bleeding p value represents the probability that Q produces less bleeding than P. is inappropriate because a p value is calculated under the null hypothesis; it is not the probability that one treatment is better or worse."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The bleeding p value represents the probability that Q produces less bleeding than P. is inappropriate because a p value is calculated under the null hypothesis; it is not the probability that one treatment is better or worse."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The nonsignificant clinical outcomes prove that P and Q are therapeutically equivalent. is inappropriate because failure to detect a significant difference is not proof of equivalence; equivalence requires a prespecified equivalence design, margins, and appropriate confidence-interval analysis."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The nonsignificant clinical outcomes prove that P and Q are therapeutically equivalent. is inappropriate because failure to detect a significant difference is not proof of equivalence; equivalence requires a prespecified equivalence design, margins, and appropriate confidence-interval analysis."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The trial establishes that P is noninferior to Q for recurrent thrombosis. is inappropriate because noninferiority cannot be inferred from an ordinary nonsignificant superiority comparison. It requires a prespecified noninferiority margin and analysis showing the treatment effect excludes unacceptable inferiority."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The trial establishes that P is noninferior to Q for recurrent thrombosis. is inappropriate because noninferiority cannot be inferred from an ordinary nonsignificant superiority comparison. It requires a prespecified noninferiority margin and analysis showing the treatment effect excludes unacceptable inferiority."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Because all clinical outcomes numerically favor P, the trial demonstrates P\u0027s overall superiority. is inappropriate because consistently favorable point estimates do not demonstrate overall superiority when the recurrence, bleeding, and mortality comparisons are nonsignificant."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Because all clinical outcomes numerically favor P, the trial demonstrates P\u0027s overall superiority. is inappropriate because consistently favorable point estimates do not demonstrate overall superiority when the recurrence, bleeding, and mortality comparisons are nonsignificant."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The statistically significant hospitalization result proves that anticoagulant P itself caused the shorter stay. is inappropriate because the trial detected a difference between treatment strategies that combined different drugs and settings. It cannot isolate a pharmacologic effect of P from the planned home-versus-inpatient administration strategy."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The statistically significant hospitalization result proves that anticoagulant P itself caused the shorter stay. is inappropriate because the trial detected a difference between treatment strategies that combined different drugs and settings. It cannot isolate a pharmacologic effect of P from the planned home-versus-inpatient administration strategy."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The hospital-stay difference should be dismissed because testing four outcomes necessarily makes p\u003C0.001 nonsignificant. is inappropriate because multiplicity can increase false-positive risk, but even a simple Bonferroni threshold for four tests would be 0.0125; the reported p\u003C0.001 remains below it. The stem also does not justify automatically discarding the finding."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The hospital-stay difference should be dismissed because testing four outcomes necessarily makes p\u003C0.001 nonsignificant. is inappropriate because multiplicity can increase false-positive risk, but even a simple Bonferroni threshold for four tests would be 0.0125; the reported p\u003C0.001 remains below it. The stem also does not justify automatically discarding the finding."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Enrollment of 600 patients eliminates the possibility that clinically important differences in recurrence, bleeding, or mortality were missed. is inappropriate because sample size alone does not eliminate type II error. The nonsignificant outcomes may still have clinically relevant uncertainty, which would be assessed with effect estimates and confidence intervals."
            },
            {
              "id": "B",
              "text": "Option A: Anticoagulant P has been proven to prevent more recurrent thromboses than anticoagulant Q. is inappropriate because the recurrence p value is 0.34, so the study did not demonstrate superior prevention with P."
            },
            {
              "id": "C",
              "text": "Option B: Anticoagulant P directly causes death in 2.3% of treated patients. is inappropriate because mortality among recipients is an observed outcome, not proof that the treatment caused those deaths."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Enrollment of 600 patients eliminates the possibility that clinically important differences in recurrence, bleeding, or mortality were missed. is inappropriate because sample size alone does not eliminate type II error. The nonsignificant outcomes may still have clinically relevant uncertainty, which would be assessed with effect estimates and confidence intervals."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i002-amyotrophic-lateral-sclerosis-testing",
      "expectedHashes": {
        "ranaze_step3_uat": "fa5fbe9e314b7d86fc0af0e5d3f264046f2befaf1660f695f8539321579d0dcb",
        "ranaze_step3_prd": "fa5fbe9e314b7d86fc0af0e5d3f264046f2befaf1660f695f8539321579d0dcb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
            },
            {
              "id": "B",
              "text": "Option C: MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
            },
            {
              "id": "C",
              "text": "Option D: Positron emission tomography of the brain is inappropriate because brain PET is not the standard confirmatory study for combined upper and lower motor neuron findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
            },
            {
              "id": "C",
              "text": "Option D: Positron emission tomography of the brain is inappropriate because brain PET is not the standard confirmatory study for combined upper and lower motor neuron findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Positron emission tomography of the brain is inappropriate because brain PET is not the standard confirmatory study for combined upper and lower motor neuron findings."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Positron emission tomography of the brain is inappropriate because brain PET is not the standard confirmatory study for combined upper and lower motor neuron findings."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Visual evoked-potential testing is inappropriate because visual evoked potentials evaluate visual pathway conduction and do not assess diffuse motor neuron degeneration."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Visual evoked-potential testing is inappropriate because visual evoked potentials evaluate visual pathway conduction and do not assess diffuse motor neuron degeneration."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Skeletal muscle biopsy is inappropriate because a muscle biopsy evaluates primary myopathies, which generally produce lower motor neuron-pattern weakness without fasciculations or pathologic upper motor neuron signs. It would not establish ALS in this patient with combined upper and lower motor neuron findings."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Skeletal muscle biopsy is inappropriate because a muscle biopsy evaluates primary myopathies, which generally produce lower motor neuron-pattern weakness without fasciculations or pathologic upper motor neuron signs. It would not establish ALS in this patient with combined upper and lower motor neuron findings."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repetitive nerve stimulation evaluates neuromuscular-junction transmission, especially when myasthenia gravis is suspected. Myasthenia does not cause muscle denervation, fasciculations, brisk reflexes, or extensor plantar responses."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repetitive nerve stimulation evaluates neuromuscular-junction transmission, especially when myasthenia gravis is suspected. Myasthenia does not cause muscle denervation, fasciculations, brisk reflexes, or extensor plantar responses."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum vitamin B12 and methylmalonic acid measurements is inappropriate because vitamin B12 deficiency can cause corticospinal-tract dysfunction but ordinarily also affects posterior-column or peripheral sensory pathways. Testing for it would not document the diffuse active and chronic motor denervation needed here."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum vitamin B12 and methylmalonic acid measurements is inappropriate because vitamin B12 deficiency can cause corticospinal-tract dysfunction but ordinarily also affects posterior-column or peripheral sensory pathways. Testing for it would not document the diffuse active and chronic motor denervation needed here."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum anti-GM1 antibody testing is inappropriate because anti-GM1 antibodies may support multifocal motor neuropathy in the appropriate setting, but that disorder causes a purely lower motor neuron-pattern, usually asymmetric distal weakness without bulbar or upper motor neuron findings. It is not the best study for this presentation."
            },
            {
              "id": "B",
              "text": "Option B: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because cerebrospinal fluid analysis is useful for inflammatory or infectious neurologic disease, which is not suggested by this pattern."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the lumbosacral spine is inappropriate because a lumbosacral lesion would not explain tongue fasciculations and intrinsic hand-muscle atrophy in addition to leg weakness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum anti-GM1 antibody testing is inappropriate because anti-GM1 antibodies may support multifocal motor neuropathy in the appropriate setting, but that disorder causes a purely lower motor neuron-pattern, usually asymmetric distal weakness without bulbar or upper motor neuron findings. It is not the best study for this presentation."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i006-lower-urinary-tract-symptoms-urinalysis",
      "expectedHashes": {
        "ranaze_step3_uat": "5cb9222db57f3f0e37a6a872eaf16c2a508ed3ff2e9f138e99045fd39d72080b",
        "ranaze_step3_prd": "5cb9222db57f3f0e37a6a872eaf16c2a508ed3ff2e9f138e99045fd39d72080b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "B",
              "text": "Option C: Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            },
            {
              "id": "C",
              "text": "Option D: Serum prostate-specific antigen measurement is inappropriate because prostate-specific antigen testing is an optional prostate cancer screening test requiring shared decision-making; lower urinary tract symptoms alone do not mandate it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            },
            {
              "id": "B",
              "text": "Option B: CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "C",
              "text": "Option D: Serum prostate-specific antigen measurement is inappropriate because prostate-specific antigen testing is an optional prostate cancer screening test requiring shared decision-making; lower urinary tract symptoms alone do not mandate it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum prostate-specific antigen measurement is inappropriate because prostate-specific antigen testing is an optional prostate cancer screening test requiring shared decision-making; lower urinary tract symptoms alone do not mandate it."
            },
            {
              "id": "B",
              "text": "Option B: CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum prostate-specific antigen measurement is inappropriate because prostate-specific antigen testing is an optional prostate cancer screening test requiring shared decision-making; lower urinary tract symptoms alone do not mandate it."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plain radiography of the kidneys, ureters, and bladder is inappropriate because plain radiography has little value in the initial evaluation of uncomplicated lower urinary tract symptoms and is primarily useful for selected radiopaque stones."
            },
            {
              "id": "B",
              "text": "Option B: CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plain radiography of the kidneys, ureters, and bladder is inappropriate because plain radiography has little value in the initial evaluation of uncomplicated lower urinary tract symptoms and is primarily useful for selected radiopaque stones."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A urine culture is appropriate when urinalysis or symptoms suggest infection. With no dysuria or fever, urinalysis should first screen for leukocytes and nitrites rather than proceeding directly to culture."
            },
            {
              "id": "B",
              "text": "Option B: CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A urine culture is appropriate when urinalysis or symptoms suggest infection. With no dysuria or fever, urinalysis should first screen for leukocytes and nitrites rather than proceeding directly to culture."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urine cytology is not part of the routine initial evaluation of uncomplicated lower urinary tract symptoms. It is used selectively when urothelial malignancy is suspected, particularly in an appropriate hematuria evaluation."
            },
            {
              "id": "B",
              "text": "Option B: CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urine cytology is not part of the routine initial evaluation of uncomplicated lower urinary tract symptoms. It is used selectively when urothelial malignancy is suspected, particularly in an appropriate hematuria evaluation."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cystoscopy is reserved for selected patients with findings such as hematuria, recurrent infection, pain, sterile pyuria, profound symptoms, or suspected structural disease. None is established here."
            },
            {
              "id": "B",
              "text": "Option B: CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cystoscopy is reserved for selected patients with findings such as hematuria, recurrent infection, pain, sterile pyuria, profound symptoms, or suspected structural disease. None is established here."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Uroflowmetry can quantify urinary flow and is commonly used during specialist evaluation, but guidelines do not recommend it routinely before the basic initial evaluation, which includes urinalysis."
            },
            {
              "id": "B",
              "text": "Option B: CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Uroflowmetry can quantify urinary flow and is commonly used during specialist evaluation, but guidelines do not recommend it routinely before the basic initial evaluation, which includes urinalysis."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure the postvoid residual urine volume is inappropriate because postvoid residual measurement can quantify incomplete bladder emptying and is useful in selected patients or during specialist evaluation, but it is not the preferred additional test in this uncomplicated initial assessment. Urinalysis should first screen for hematuria, infection, glycosuria, and other conditions that can cause or complicate lower urinary tract symptoms."
            },
            {
              "id": "B",
              "text": "Option B: CT urography is generally reserved for upper urinary tract evaluation when indicated by findings such as hematuria and is not routine for uncomplicated voiding symptoms."
            },
            {
              "id": "C",
              "text": "Option C: Renal and bladder ultrasonography is inappropriate because ultrasonography may be appropriate when retention, hydronephrosis, renal dysfunction, stones, or recurrent infections are suspected, none of which is established here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure the postvoid residual urine volume is inappropriate because postvoid residual measurement can quantify incomplete bladder emptying and is useful in selected patients or during specialist evaluation, but it is not the preferred additional test in this uncomplicated initial assessment. Urinalysis should first screen for hematuria, infection, glycosuria, and other conditions that can cause or complicate lower urinary tract symptoms."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i007-patient-centered-opening",
      "expectedHashes": {
        "ranaze_step3_uat": "10c0ab35a0638f96e5824c6511aafc8da532595a7f2a51b79c076b3710960702",
        "ranaze_step3_prd": "10c0ab35a0638f96e5824c6511aafc8da532595a7f2a51b79c076b3710960702"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Are you feeling depressed?\u0022 is inappropriate because this labels a possible diagnosis before the patient has described his experience."
            },
            {
              "id": "B",
              "text": "Option B: \u0022Has anyone in your family had depression?\u0022 is inappropriate because family history may be relevant later but does not explore the patient\u0027s current concern."
            },
            {
              "id": "C",
              "text": "Option D: \u0022How many hours are you sleeping each night?\u0022 is inappropriate because sleep should be assessed, but this narrow question is not the best initial approach."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Are you feeling depressed?\u0022 is inappropriate because this labels a possible diagnosis before the patient has described his experience."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Has anyone in your family had depression?\u0022 is inappropriate because family history may be relevant later but does not explore the patient\u0027s current concern."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Are you feeling depressed?\u0022 is inappropriate because this labels a possible diagnosis before the patient has described his experience."
            },
            {
              "id": "C",
              "text": "Option D: \u0022How many hours are you sleeping each night?\u0022 is inappropriate because sleep should be assessed, but this narrow question is not the best initial approach."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Has anyone in your family had depression?\u0022 is inappropriate because family history may be relevant later but does not explore the patient\u0027s current concern."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022How many hours are you sleeping each night?\u0022 is inappropriate because sleep should be assessed, but this narrow question is not the best initial approach."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Are you feeling depressed?\u0022 is inappropriate because this labels a possible diagnosis before the patient has described his experience."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has anyone in your family had depression?\u0022 is inappropriate because family history may be relevant later but does not explore the patient\u0027s current concern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022How many hours are you sleeping each night?\u0022 is inappropriate because sleep should be assessed, but this narrow question is not the best initial approach."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Are there problems at home causing you stress?\u0022 is inappropriate because this prematurely assumes that home problems are present."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Are you feeling depressed?\u0022 is inappropriate because this labels a possible diagnosis before the patient has described his experience."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has anyone in your family had depression?\u0022 is inappropriate because family history may be relevant later but does not explore the patient\u0027s current concern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Are there problems at home causing you stress?\u0022 is inappropriate because this prematurely assumes that home problems are present."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Is stress at work making you feel worn out?\u0022 is inappropriate because this closed question prematurely assumes both an external stressor and its location. No occupational problem is stated, so broad exploration should precede focused questions."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Are you feeling depressed?\u0022 is inappropriate because this labels a possible diagnosis before the patient has described his experience."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has anyone in your family had depression?\u0022 is inappropriate because family history may be relevant later but does not explore the patient\u0027s current concern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Is stress at work making you feel worn out?\u0022 is inappropriate because this closed question prematurely assumes both an external stressor and its location. No occupational problem is stated, so broad exploration should precede focused questions."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I will order thyroid and anemia tests to find the cause of your fatigue.\u0022 is inappropriate because fatigue can require medical evaluation, but immediately announcing selected tests bypasses history-taking and assumes a biomedical cause before clarifying what \u0027worn out\u0027 means to this patient."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Are you feeling depressed?\u0022 is inappropriate because this labels a possible diagnosis before the patient has described his experience."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has anyone in your family had depression?\u0022 is inappropriate because family history may be relevant later but does not explore the patient\u0027s current concern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I will order thyroid and anemia tests to find the cause of your fatigue.\u0022 is inappropriate because fatigue can require medical evaluation, but immediately announcing selected tests bypasses history-taking and assumes a biomedical cause before clarifying what \u0027worn out\u0027 means to this patient."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i008-coarctation-exam",
      "expectedHashes": {
        "ranaze_step3_uat": "ce057e2613ccffa972a1cce0d4e5f24a0e634462f2273bf528e2afb0db760b04",
        "ranaze_step3_prd": "ce057e2613ccffa972a1cce0d4e5f24a0e634462f2273bf528e2afb0db760b04"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "B",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            },
            {
              "id": "C",
              "text": "Option D: A palpable enlarged liver is inappropriate because hepatomegaly would suggest heart failure, which is not indicated here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option D: A palpable enlarged liver is inappropriate because hepatomegaly would suggest heart failure, which is not indicated here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A palpable enlarged liver is inappropriate because hepatomegaly would suggest heart failure, which is not indicated here."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A palpable enlarged liver is inappropriate because hepatomegaly would suggest heart failure, which is not indicated here."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nail pitting of multiple fingernails is inappropriate because nail pitting is associated with conditions such as psoriasis and does not explain this cardiovascular presentation."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nail pitting of multiple fingernails is inappropriate because nail pitting is associated with conditions such as psoriasis and does not explain this cardiovascular presentation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bounding femoral pulses with a widened pulse pressure is inappropriate because bounding pulses and a widened pulse pressure suggest patent ductus arteriosus or aortic regurgitation, whereas coarctation reduces lower-extremity pulse amplitude."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bounding femoral pulses with a widened pulse pressure is inappropriate because bounding pulses and a widened pulse pressure suggest patent ductus arteriosus or aortic regurgitation, whereas coarctation reduces lower-extremity pulse amplitude."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A fixed, widely split second heart sound is inappropriate because a fixed, widely split S2 suggests an atrial septal defect and does not explain upper-extremity hypertension with a posterior murmur."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A fixed, widely split second heart sound is inappropriate because a fixed, widely split S2 suggests an atrial septal defect and does not explain upper-extremity hypertension with a posterior murmur."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A palpable abdominal mass is inappropriate because an abdominal mass may suggest a renal tumor or cystic renal disease as a cause of pediatric hypertension, but it does not account for the murmur localized to the upper back."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A palpable abdominal mass is inappropriate because an abdominal mass may suggest a renal tumor or cystic renal disease as a cause of pediatric hypertension, but it does not account for the murmur localized to the upper back."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An abdominal bruit suggests renovascular hypertension or a midaortic lesion; the posterior thoracic murmur instead localizes the obstruction to the aortic arch region."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An abdominal bruit suggests renovascular hypertension or a midaortic lesion; the posterior thoracic murmur instead localizes the obstruction to the aortic arch region."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thyroid enlargement with a fine tremor is inappropriate because thyroid enlargement and tremor would support hyperthyroidism, which may cause systolic hypertension but not the characteristic interscapular murmur of coarctation."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thyroid enlargement with a fine tremor is inappropriate because thyroid enlargement and tremor would support hyperthyroidism, which may cause systolic hypertension but not the characteristic interscapular murmur of coarctation."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Moon facies with violaceous abdominal striae is inappropriate because moon facies and violaceous striae suggest glucocorticoid excess, an alternative cause of hypertension that does not explain this localized back murmur."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Moon facies with violaceous abdominal striae is inappropriate because moon facies and violaceous striae suggest glucocorticoid excess, an alternative cause of hypertension that does not explain this localized back murmur."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acanthosis nigricans at the posterior neck is inappropriate because acanthosis nigricans supports insulin resistance and obesity-associated primary hypertension; this child is not obese and has a murmur suggesting a structural lesion."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acanthosis nigricans at the posterior neck is inappropriate because acanthosis nigricans supports insulin resistance and obesity-associated primary hypertension; this child is not obese and has a murmur suggesting a structural lesion."
        },
        "M": {
          "prompt": "Which feature of option M should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Caf\u00E9-au-lait macules with axillary freckling is inappropriate because neurofibromatosis can be associated with renovascular hypertension, but its skin findings would not explain the characteristic posterior murmur."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Caf\u00E9-au-lait macules with axillary freckling is inappropriate because neurofibromatosis can be associated with renovascular hypertension, but its skin findings would not explain the characteristic posterior murmur."
        },
        "N": {
          "prompt": "Which feature of option N should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A hyperdynamic precordium with a continuous infraclavicular murmur is inappropriate because a continuous infraclavicular murmur with a hyperdynamic precordium suggests patent ductus arteriosus; this stem describes a systolic murmur over the left upper back."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A hyperdynamic precordium with a continuous infraclavicular murmur is inappropriate because a continuous infraclavicular murmur with a hyperdynamic precordium suggests patent ductus arteriosus; this stem describes a systolic murmur over the left upper back."
        },
        "O": {
          "prompt": "Which feature of option O should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An apical holosystolic murmur radiating to the axilla suggests mitral regurgitation and does not fit the posterior murmur or pediatric upper-extremity hypertension."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An apical holosystolic murmur radiating to the axilla suggests mitral regurgitation and does not fit the posterior murmur or pediatric upper-extremity hypertension."
        },
        "P": {
          "prompt": "Which feature of option P should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Weak pulses in all four extremities is inappropriate because coarctation produces strong upper-extremity pulses with diminished lower-extremity pulses; globally weak pulses suggest low cardiac output or another obstructive lesion."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Weak pulses in all four extremities is inappropriate because coarctation produces strong upper-extremity pulses with diminished lower-extremity pulses; globally weak pulses suggest low cardiac output or another obstructive lesion."
        },
        "Q": {
          "prompt": "Which feature of option Q should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A prominent right ventricular heave is inappropriate because a right ventricular heave suggests right-sided pressure or volume overload. Older children with coarctation more typically develop left ventricular pressure overload."
            },
            {
              "id": "B",
              "text": "Option B: A supernumerary nipple along the milk line is inappropriate because a supernumerary nipple is not a typical finding in coarctation."
            },
            {
              "id": "C",
              "text": "Option C: A lateral neck sinus opening is inappropriate because a branchial anomaly does not explain hypertension and a posterior systolic murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A prominent right ventricular heave is inappropriate because a right ventricular heave suggests right-sided pressure or volume overload. Older children with coarctation more typically develop left ventricular pressure overload."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i009-traumatic-hemothorax",
      "expectedHashes": {
        "ranaze_step3_uat": "e93061a34e5799ba50cae7cb99add8a531e3eb48ea205a73926418f4b0746e13",
        "ranaze_step3_prd": "e93061a34e5799ba50cae7cb99add8a531e3eb48ea205a73926418f4b0746e13"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "B",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            },
            {
              "id": "C",
              "text": "Option C: Blood within the lung parenchyma is inappropriate because intraparenchymal hemorrhage remains within lung tissue and does not freely layer with body position."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option C: Blood within the lung parenchyma is inappropriate because intraparenchymal hemorrhage remains within lung tissue and does not freely layer with body position."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Blood within the lung parenchyma is inappropriate because intraparenchymal hemorrhage remains within lung tissue and does not freely layer with body position."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Blood within the lung parenchyma is inappropriate because intraparenchymal hemorrhage remains within lung tissue and does not freely layer with body position."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Air within the pleural space is inappropriate because pleural air is low attenuation and rises to the nondependent portion of the hemithorax."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Air within the pleural space is inappropriate because pleural air is low attenuation and rises to the nondependent portion of the hemithorax."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A simple serous pleural effusion is inappropriate because simple serous pleural fluid may shift dependently, but it generally has low attenuation; high-attenuation pleural fluid immediately after trauma indicates blood."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A simple serous pleural effusion is inappropriate because simple serous pleural fluid may shift dependently, but it generally has low attenuation; high-attenuation pleural fluid immediately after trauma indicates blood."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An extrapleural chest-wall hematoma is inappropriate because an extrapleural hematoma is confined by the chest wall and extrapleural tissues and would not move freely from posterior to anterior pleural space with repositioning."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An extrapleural chest-wall hematoma is inappropriate because an extrapleural hematoma is confined by the chest wall and extrapleural tissues and would not move freely from posterior to anterior pleural space with repositioning."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dependent atelectasis of the left lung is inappropriate because dependent atelectasis is collapsed lung parenchyma rather than a mobile high-attenuation pleural-fluid crescent."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dependent atelectasis of the left lung is inappropriate because dependent atelectasis is collapsed lung parenchyma rather than a mobile high-attenuation pleural-fluid crescent."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A pulmonary contusion produces parenchymal ground-glass opacity or consolidation and remains fixed within injured lung rather than layering with gravity."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A pulmonary contusion produces parenchymal ground-glass opacity or consolidation and remains fixed within injured lung rather than layering with gravity."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A subpleural pulmonary hematoma is confined within lung tissue and would not shift to the newly dependent pleural surface."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A subpleural pulmonary hematoma is confined within lung tissue and would not shift to the newly dependent pleural surface."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chyle within the pleural space is inappropriate because chylothorax is usually low-attenuation pleural fluid and is not expected to appear as an acute high-attenuation collection after this blunt impact."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chyle within the pleural space is inappropriate because chylothorax is usually low-attenuation pleural fluid and is not expected to appear as an acute high-attenuation collection after this blunt impact."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Focal pleural thickening from prior inflammation is inappropriate because pleural thickening is attached to the pleural surface and cannot migrate from posterior to anterior with patient repositioning."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Focal pleural thickening from prior inflammation is inappropriate because pleural thickening is attached to the pleural surface and cannot migrate from posterior to anterior with patient repositioning."
        },
        "M": {
          "prompt": "Which feature of option M should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Herniated abdominal tissue through a diaphragmatic tear is inappropriate because herniated abdominal tissue has soft-tissue or organ morphology and remains related to a diaphragmatic defect rather than freely layering as pleural fluid."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Herniated abdominal tissue through a diaphragmatic tear is inappropriate because herniated abdominal tissue has soft-tissue or organ morphology and remains related to a diaphragmatic defect rather than freely layering as pleural fluid."
        },
        "N": {
          "prompt": "Which feature of option N should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A motion artifact caused by respiration is inappropriate because a respiratory motion artifact would blur or misregister anatomy rather than repeatedly place a fluid crescent in the gravitationally dependent pleural space."
            },
            {
              "id": "B",
              "text": "Option A: Blood within the pericardial sac is inappropriate because hemopericardium would surround the heart and would not shift between posterior and anterior pleural locations with repositioning."
            },
            {
              "id": "C",
              "text": "Option B: Blood within a bronchus is inappropriate because endobronchial blood would be located in the airways rather than forming a dependent pleural collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A motion artifact caused by respiration is inappropriate because a respiratory motion artifact would blur or misregister anatomy rather than repeatedly place a fluid crescent in the gravitationally dependent pleural space."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i010-test-specificity",
      "expectedHashes": {
        "ranaze_step3_uat": "f16dd8595cf3e53edcb2a2a799669d9f2127edba7be58f3c7fb4f8c391ad1982",
        "ranaze_step3_prd": "f16dd8595cf3e53edcb2a2a799669d9f2127edba7be58f3c7fb4f8c391ad1982"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low cost is inappropriate because cost affects test selection but does not determine how well a positive result confirms disease."
            },
            {
              "id": "B",
              "text": "Option B: High negative predictive value is inappropriate because negative predictive value is most useful when interpreting a negative result and also varies with disease prevalence."
            },
            {
              "id": "C",
              "text": "Option C: High interobserver reliability is inappropriate because reliability describes reproducibility, not the ability of a positive result to confirm disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low cost is inappropriate because cost affects test selection but does not determine how well a positive result confirms disease."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High negative predictive value is inappropriate because negative predictive value is most useful when interpreting a negative result and also varies with disease prevalence."
            },
            {
              "id": "B",
              "text": "Option A: Low cost is inappropriate because cost affects test selection but does not determine how well a positive result confirms disease."
            },
            {
              "id": "C",
              "text": "Option C: High interobserver reliability is inappropriate because reliability describes reproducibility, not the ability of a positive result to confirm disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High negative predictive value is inappropriate because negative predictive value is most useful when interpreting a negative result and also varies with disease prevalence."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High interobserver reliability is inappropriate because reliability describes reproducibility, not the ability of a positive result to confirm disease."
            },
            {
              "id": "B",
              "text": "Option A: Low cost is inappropriate because cost affects test selection but does not determine how well a positive result confirms disease."
            },
            {
              "id": "C",
              "text": "Option B: High negative predictive value is inappropriate because negative predictive value is most useful when interpreting a negative result and also varies with disease prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High interobserver reliability is inappropriate because reliability describes reproducibility, not the ability of a positive result to confirm disease."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High sensitivity is most useful when a negative result is needed to rule out disease."
            },
            {
              "id": "B",
              "text": "Option A: Low cost is inappropriate because cost affects test selection but does not determine how well a positive result confirms disease."
            },
            {
              "id": "C",
              "text": "Option B: High negative predictive value is inappropriate because negative predictive value is most useful when interpreting a negative result and also varies with disease prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High sensitivity is most useful when a negative result is needed to rule out disease."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High overall diagnostic accuracy is inappropriate because overall accuracy combines correct positive and negative classifications and varies with the tested population; it does not specifically ensure that a positive result rules in disease as high specificity does."
            },
            {
              "id": "B",
              "text": "Option A: Low cost is inappropriate because cost affects test selection but does not determine how well a positive result confirms disease."
            },
            {
              "id": "C",
              "text": "Option B: High negative predictive value is inappropriate because negative predictive value is most useful when interpreting a negative result and also varies with disease prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High overall diagnostic accuracy is inappropriate because overall accuracy combines correct positive and negative classifications and varies with the tested population; it does not specifically ensure that a positive result rules in disease as high specificity does."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A low negative likelihood ratio makes a negative test useful for ruling disease out; confirmation after a positive result instead requires strong rule-in performance."
            },
            {
              "id": "B",
              "text": "Option A: Low cost is inappropriate because cost affects test selection but does not determine how well a positive result confirms disease."
            },
            {
              "id": "C",
              "text": "Option B: High negative predictive value is inappropriate because negative predictive value is most useful when interpreting a negative result and also varies with disease prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A low negative likelihood ratio makes a negative test useful for ruling disease out; confirmation after a positive result instead requires strong rule-in performance."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High analytic precision on repeated measurements is inappropriate because analytic precision means repeated measurements agree. It does not establish diagnostic validity or prevent false-positive results in patients without disease."
            },
            {
              "id": "B",
              "text": "Option A: Low cost is inappropriate because cost affects test selection but does not determine how well a positive result confirms disease."
            },
            {
              "id": "C",
              "text": "Option B: High negative predictive value is inappropriate because negative predictive value is most useful when interpreting a negative result and also varies with disease prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High analytic precision on repeated measurements is inappropriate because analytic precision means repeated measurements agree. It does not establish diagnostic validity or prevent false-positive results in patients without disease."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i011-nonmaleficence-elective-surgery",
      "expectedHashes": {
        "ranaze_step3_uat": "d8b0b8a6358207e72ba0873668943598dbd08c8b8eb731f928c918c5d1570653",
        "ranaze_step3_prd": "d8b0b8a6358207e72ba0873668943598dbd08c8b8eb731f928c918c5d1570653"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "B",
              "text": "Option C: Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            },
            {
              "id": "C",
              "text": "Option D: Hospitalize the patient for orchiectomy because outpatient treatment is an inequitable use of resources is inappropriate because distributive justice does not justify hospitalization and surgery that are not medically indicated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            },
            {
              "id": "B",
              "text": "Option A: Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "C",
              "text": "Option D: Hospitalize the patient for orchiectomy because outpatient treatment is an inequitable use of resources is inappropriate because distributive justice does not justify hospitalization and surgery that are not medically indicated."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hospitalize the patient for orchiectomy because outpatient treatment is an inequitable use of resources is inappropriate because distributive justice does not justify hospitalization and surgery that are not medically indicated."
            },
            {
              "id": "B",
              "text": "Option A: Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "C",
              "text": "Option C: Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hospitalize the patient for orchiectomy because outpatient treatment is an inequitable use of resources is inappropriate because distributive justice does not justify hospitalization and surgery that are not medically indicated."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange orchiectomy during this visit because it would provide the greatest immediate benefit is inappropriate because immediate pain relief does not make elective orchiectomy appropriate when the pain is due to a treatable acute infection."
            },
            {
              "id": "B",
              "text": "Option A: Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "C",
              "text": "Option C: Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange orchiectomy during this visit because it would provide the greatest immediate benefit is inappropriate because immediate pain relief does not make elective orchiectomy appropriate when the pain is due to a treatable acute infection."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform immediate scrotal exploration for presumed testicular torsion is inappropriate because scrotal exploration is indicated when testicular torsion is suspected. The urethral discharge, dysuria, tender enlarged epididymis, normal testicular lie, and intact cremasteric reflex instead support acute epididymitis."
            },
            {
              "id": "B",
              "text": "Option A: Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "C",
              "text": "Option C: Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform immediate scrotal exploration for presumed testicular torsion is inappropriate because scrotal exploration is indicated when testicular torsion is suspected. The urethral discharge, dysuria, tender enlarged epididymis, normal testicular lie, and intact cremasteric reflex instead support acute epididymitis."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain urethral testing and defer antimicrobial therapy until the organism is identified is inappropriate because presumptive antimicrobial treatment for sexually active patients with acute epididymitis should begin at the visit, before laboratory results are available, to prevent complications and STI transmission."
            },
            {
              "id": "B",
              "text": "Option A: Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "C",
              "text": "Option C: Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain urethral testing and defer antimicrobial therapy until the organism is identified is inappropriate because presumptive antimicrobial treatment for sexually active patients with acute epididymitis should begin at the visit, before laboratory results are available, to prevent complications and STI transmission."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide analgesics and scrotal support without antimicrobial therapy is inappropriate because analgesia, rest, and scrotal elevation are useful adjuncts but do not eradicate the likely infection; indicated antimicrobial therapy must also be given."
            },
            {
              "id": "B",
              "text": "Option A: Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "C",
              "text": "Option C: Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide analgesics and scrotal support without antimicrobial therapy is inappropriate because analgesia, rest, and scrotal elevation are useful adjuncts but do not eradicate the likely infection; indicated antimicrobial therapy must also be given."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hospitalize the patient for broad-spectrum intravenous antibiotics is inappropriate because most acute epididymitis can be treated as an outpatient. This stable patient has only a low-grade fever and no described abscess, infarction, necrotizing infection, inability to take medication, or other reason for admission."
            },
            {
              "id": "B",
              "text": "Option A: Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "C",
              "text": "Option C: Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hospitalize the patient for broad-spectrum intravenous antibiotics is inappropriate because most acute epididymitis can be treated as an outpatient. This stable patient has only a low-grade fever and no described abscess, infarction, necrotizing infection, inability to take medication, or other reason for admission."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain scrotal Doppler ultrasonography before initiating antimicrobial treatment is inappropriate because scrotal Doppler ultrasonography is reserved principally for suspected torsion or an uncertain diagnosis. This patient has purulent urethral drainage, a tender enlarged epididymis, normal testicular lie, and an intact cremasteric reflex, making infectious epididymitis clinically established. Imaging should not delay indicated presumptive antimicrobial therapy."
            },
            {
              "id": "B",
              "text": "Option A: Perform bilateral orchiectomy immediately because the patient has capacity to request it is inappropriate because patient autonomy does not obligate a clinician to perform a medically inappropriate irreversible procedure during an acute infection."
            },
            {
              "id": "C",
              "text": "Option C: Decline all treatment until the patient completes the specialty-program evaluations is inappropriate because the patient should not be denied indicated treatment for the acute infection while elective-surgery evaluation is pending."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain scrotal Doppler ultrasonography before initiating antimicrobial treatment is inappropriate because scrotal Doppler ultrasonography is reserved principally for suspected torsion or an uncertain diagnosis. This patient has purulent urethral drainage, a tender enlarged epididymis, normal testicular lie, and an intact cremasteric reflex, making infectious epididymitis clinically established. Imaging should not delay indicated presumptive antimicrobial therapy."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i012-law-ethics-integration",
      "expectedHashes": {
        "ranaze_step3_uat": "85409b4aa99ea8e1323e5b6b8f9fc61aebb0c9de52f7ad294101e680bf5443c9",
        "ranaze_step3_prd": "85409b4aa99ea8e1323e5b6b8f9fc61aebb0c9de52f7ad294101e680bf5443c9"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
            },
            {
              "id": "B",
              "text": "Option B: The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
            },
            {
              "id": "C",
              "text": "Option D: The legal requirement eliminates the need to consider ethical principles is inappropriate because legal requirements constrain action but do not erase ethical duties such as respect for autonomy and avoidance of harm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
            },
            {
              "id": "B",
              "text": "Option A: The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
            },
            {
              "id": "C",
              "text": "Option D: The legal requirement eliminates the need to consider ethical principles is inappropriate because legal requirements constrain action but do not erase ethical duties such as respect for autonomy and avoidance of harm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The legal requirement eliminates the need to consider ethical principles is inappropriate because legal requirements constrain action but do not erase ethical duties such as respect for autonomy and avoidance of harm."
            },
            {
              "id": "B",
              "text": "Option A: The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
            },
            {
              "id": "C",
              "text": "Option B: The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The legal requirement eliminates the need to consider ethical principles is inappropriate because legal requirements constrain action but do not erase ethical duties such as respect for autonomy and avoidance of harm."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A capable patient\u0027s preference alone determines the legally permissible action is inappropriate because decision-making capacity supports participation in decisions but does not authorize an action prohibited by law."
            },
            {
              "id": "B",
              "text": "Option A: The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
            },
            {
              "id": "C",
              "text": "Option B: The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A capable patient\u0027s preference alone determines the legally permissible action is inappropriate because decision-making capacity supports participation in decisions but does not authorize an action prohibited by law."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The physician may disregard the statute when professional judgment favors the procedure is inappropriate because professional judgment does not authorize a physician to ignore an applicable statute. Ethical disagreement may justify advocacy to change a law, not unilateral violation."
            },
            {
              "id": "B",
              "text": "Option A: The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
            },
            {
              "id": "C",
              "text": "Option B: The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The physician may disregard the statute when professional judgment favors the procedure is inappropriate because professional judgment does not authorize a physician to ignore an applicable statute. Ethical disagreement may justify advocacy to change a law, not unilateral violation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Once the patient enrolls in the licensed program, the procedure becomes ethically obligatory is inappropriate because compliance with a legal prerequisite makes the procedure legally available but does not itself establish that surgery is ethically or clinically required. Benefits, harms, alternatives, and voluntary consent still matter."
            },
            {
              "id": "B",
              "text": "Option A: The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
            },
            {
              "id": "C",
              "text": "Option B: The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Once the patient enrolls in the licensed program, the procedure becomes ethically obligatory is inappropriate because compliance with a legal prerequisite makes the procedure legally available but does not itself establish that surgery is ethically or clinically required. Benefits, harms, alternatives, and voluntary consent still matter."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An institutional policy favoring patient autonomy may supersede the state-law prerequisite is inappropriate because institutional policy cannot authorize conduct forbidden by controlling state law. The institution must operate within the statute while continuing ethical deliberation."
            },
            {
              "id": "B",
              "text": "Option A: The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
            },
            {
              "id": "C",
              "text": "Option B: The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An institutional policy favoring patient autonomy may supersede the state-law prerequisite is inappropriate because institutional policy cannot authorize conduct forbidden by controlling state law. The institution must operate within the statute while continuing ethical deliberation."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The statute permanently prohibits the procedure for this patient because enrollment did not precede the request is inappropriate because the statute imposes a prerequisite rather than a permanent prohibition. The explicit wording permits the procedure after enrollment and completion of the specified safeguards."
            },
            {
              "id": "B",
              "text": "Option A: The physician alone should resolve the ethical and legal issues is inappropriate because physicians should not decide medicolegal conflicts alone; relevant law and appropriate institutional processes matter."
            },
            {
              "id": "C",
              "text": "Option B: The institution should choose the action that minimizes its liability is inappropriate because liability concerns do not replace patient-centered ethical and legal analysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The statute permanently prohibits the procedure for this patient because enrollment did not precede the request is inappropriate because the statute imposes a prerequisite rather than a permanent prohibition. The explicit wording permits the procedure after enrollment and completion of the specified safeguards."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i013-aortic-dissection-cta",
      "expectedHashes": {
        "ranaze_step3_uat": "8bff5afb7fb1283b315e62df44b2203af1652e3dc9c105f7a735e45effb01f8f",
        "ranaze_step3_prd": "8bff5afb7fb1283b315e62df44b2203af1652e3dc9c105f7a735e45effb01f8f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
            },
            {
              "id": "B",
              "text": "Option C: Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
            },
            {
              "id": "C",
              "text": "Option D: Ventilation-perfusion scanning evaluates suspected pulmonary embolism, not the leading diagnosis here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
            },
            {
              "id": "B",
              "text": "Option B: Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
            },
            {
              "id": "C",
              "text": "Option D: Ventilation-perfusion scanning evaluates suspected pulmonary embolism, not the leading diagnosis here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ventilation-perfusion scanning evaluates suspected pulmonary embolism, not the leading diagnosis here."
            },
            {
              "id": "B",
              "text": "Option B: Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ventilation-perfusion scanning evaluates suspected pulmonary embolism, not the leading diagnosis here."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exercise stress echocardiography is inappropriate because exercise stress testing is contraindicated in suspected acute aortic dissection."
            },
            {
              "id": "B",
              "text": "Option B: Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exercise stress echocardiography is inappropriate because exercise stress testing is contraindicated in suspected acute aortic dissection."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plasma D-dimer measurement is inappropriate because a low D-dimer can contribute to exclusion of acute aortic syndrome only when pretest probability is low. This patient has several high-risk features and requires definitive imaging regardless of the result."
            },
            {
              "id": "B",
              "text": "Option B: Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plasma D-dimer measurement is inappropriate because a low D-dimer can contribute to exclusion of acute aortic syndrome only when pretest probability is low. This patient has several high-risk features and requires definitive imaging regardless of the result."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serial serum troponin measurements is inappropriate because troponin evaluates myocardial injury and may be abnormal if dissection compromises a coronary artery, but serial measurements neither diagnose nor map a dissection and would dangerously delay definitive imaging."
            },
            {
              "id": "B",
              "text": "Option B: Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serial serum troponin measurements is inappropriate because troponin evaluates myocardial injury and may be abnormal if dissection compromises a coronary artery, but serial measurements neither diagnose nor map a dissection and would dangerously delay definitive imaging."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The presentation is not led by acute coronary syndrome, and invasive coronary angiography neither reliably evaluates the full aorta nor represents the preferred initial test for suspected acute aortic syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The presentation is not led by acute coronary syndrome, and invasive coronary angiography neither reliably evaluates the full aorta nor represents the preferred initial test for suspected acute aortic syndrome."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT pulmonary angiography is optimized for pulmonary arteries and is used for suspected pulmonary embolism. The interarm blood-pressure difference, aortic-regurgitation murmur, migrating tearing pain, and widened mediastinum point instead to an aortic-protocol CTA."
            },
            {
              "id": "B",
              "text": "Option B: Cardiac MRI is accurate but is generally too slow and less available for initial emergency evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Transthoracic echocardiography may identify complications but is less sensitive for defining an acute thoracic dissection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT pulmonary angiography is optimized for pulmonary arteries and is used for suspected pulmonary embolism. The interarm blood-pressure difference, aortic-regurgitation murmur, migrating tearing pain, and widened mediastinum point instead to an aortic-protocol CTA."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i014-literature-search-community-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "d61c9f040a1dcb42a1312dc3d5a178c0620168ddc4b27bdf904ceb72e19787e9",
        "ranaze_step3_prd": "d61c9f040a1dcb42a1312dc3d5a178c0620168ddc4b27bdf904ceb72e19787e9"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request the utility company\u0027s internal risk assessment is inappropriate because the utility\u0027s assessment may be useful later but is not a substitute for an independent review of the evidence."
            },
            {
              "id": "B",
              "text": "Option C: Obtain an expert opinion before reviewing available evidence is inappropriate because expert consultation can help interpret evidence but should follow or accompany an initial review of the literature."
            },
            {
              "id": "C",
              "text": "Option D: Conduct extended interviews with apartment residents is inappropriate because resident interviews may clarify concerns but cannot establish medical safety before existing evidence is reviewed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request the utility company\u0027s internal risk assessment is inappropriate because the utility\u0027s assessment may be useful later but is not a substitute for an independent review of the evidence."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an expert opinion before reviewing available evidence is inappropriate because expert consultation can help interpret evidence but should follow or accompany an initial review of the literature."
            },
            {
              "id": "B",
              "text": "Option A: Request the utility company\u0027s internal risk assessment is inappropriate because the utility\u0027s assessment may be useful later but is not a substitute for an independent review of the evidence."
            },
            {
              "id": "C",
              "text": "Option D: Conduct extended interviews with apartment residents is inappropriate because resident interviews may clarify concerns but cannot establish medical safety before existing evidence is reviewed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an expert opinion before reviewing available evidence is inappropriate because expert consultation can help interpret evidence but should follow or accompany an initial review of the literature."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Conduct extended interviews with apartment residents is inappropriate because resident interviews may clarify concerns but cannot establish medical safety before existing evidence is reviewed."
            },
            {
              "id": "B",
              "text": "Option A: Request the utility company\u0027s internal risk assessment is inappropriate because the utility\u0027s assessment may be useful later but is not a substitute for an independent review of the evidence."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an expert opinion before reviewing available evidence is inappropriate because expert consultation can help interpret evidence but should follow or accompany an initial review of the literature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Conduct extended interviews with apartment residents is inappropriate because resident interviews may clarify concerns but cannot establish medical safety before existing evidence is reviewed."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin a case-control study of residents living near the proposed site is inappropriate because a new epidemiologic study is costly and slow and is premature before determining what evidence already exists."
            },
            {
              "id": "B",
              "text": "Option A: Request the utility company\u0027s internal risk assessment is inappropriate because the utility\u0027s assessment may be useful later but is not a substitute for an independent review of the evidence."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an expert opinion before reviewing available evidence is inappropriate because expert consultation can help interpret evidence but should follow or accompany an initial review of the literature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin a case-control study of residents living near the proposed site is inappropriate because a new epidemiologic study is costly and slow and is premature before determining what evidence already exists."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediately perform local electromagnetic-field measurements around the proposed site is inappropriate because exposure measurement may eventually help determine site-specific exposure, but the substation is only proposed and the first task is to establish from existing scientific evidence whether and under what conditions electromagnetic fields pose a health hazard."
            },
            {
              "id": "B",
              "text": "Option A: Request the utility company\u0027s internal risk assessment is inappropriate because the utility\u0027s assessment may be useful later but is not a substitute for an independent review of the evidence."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an expert opinion before reviewing available evidence is inappropriate because expert consultation can help interpret evidence but should follow or accompany an initial review of the literature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediately perform local electromagnetic-field measurements around the proposed site is inappropriate because exposure measurement may eventually help determine site-specific exposure, but the substation is only proposed and the first task is to establish from existing scientific evidence whether and under what conditions electromagnetic fields pose a health hazard."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Compare cancer rates near existing substations with countywide cancer rates is inappropriate because an ad hoc ecological comparison is vulnerable to exposure misclassification and confounding. It is premature when existing epidemiologic and risk-assessment evidence has not yet been reviewed."
            },
            {
              "id": "B",
              "text": "Option A: Request the utility company\u0027s internal risk assessment is inappropriate because the utility\u0027s assessment may be useful later but is not a substitute for an independent review of the evidence."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an expert opinion before reviewing available evidence is inappropriate because expert consultation can help interpret evidence but should follow or accompany an initial review of the literature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Compare cancer rates near existing substations with countywide cancer rates is inappropriate because an ad hoc ecological comparison is vulnerable to exposure misclassification and confounding. It is premature when existing epidemiologic and risk-assessment evidence has not yet been reviewed."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend postponing construction until local health-outcome data are collected is inappropriate because postponing construction is a risk-management decision, not the first evidence-gathering step. The physician should first characterize the existing evidence before recommending a policy action."
            },
            {
              "id": "B",
              "text": "Option A: Request the utility company\u0027s internal risk assessment is inappropriate because the utility\u0027s assessment may be useful later but is not a substitute for an independent review of the evidence."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an expert opinion before reviewing available evidence is inappropriate because expert consultation can help interpret evidence but should follow or accompany an initial review of the literature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend postponing construction until local health-outcome data are collected is inappropriate because postponing construction is a risk-management decision, not the first evidence-gathering step. The physician should first characterize the existing evidence before recommending a policy action."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i015-primary-herpetic-gingivostomatitis",
      "expectedHashes": {
        "ranaze_step3_uat": "f7d40141ea2187b79973c745028a6852a4e6ba32a5384b1337950cc6a5f31415",
        "ranaze_step3_prd": "f7d40141ea2187b79973c745028a6852a4e6ba32a5384b1337950cc6a5f31415"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure antinuclear antibody levels is inappropriate because autoimmune testing is not indicated for an acute febrile vesicular oral eruption."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a throat culture for group A Streptococcus is inappropriate because group A streptococcal pharyngitis typically causes tonsillar erythema or exudates rather than diffuse gingivitis and grouped oral vesicles."
            },
            {
              "id": "C",
              "text": "Option D: Culture an oral lesion for Streptobacillus moniliformis is inappropriate because rat-bite fever is not suggested by this localized vesicular oral syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure antinuclear antibody levels is inappropriate because autoimmune testing is not indicated for an acute febrile vesicular oral eruption."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a throat culture for group A Streptococcus is inappropriate because group A streptococcal pharyngitis typically causes tonsillar erythema or exudates rather than diffuse gingivitis and grouped oral vesicles."
            },
            {
              "id": "B",
              "text": "Option A: Measure antinuclear antibody levels is inappropriate because autoimmune testing is not indicated for an acute febrile vesicular oral eruption."
            },
            {
              "id": "C",
              "text": "Option D: Culture an oral lesion for Streptobacillus moniliformis is inappropriate because rat-bite fever is not suggested by this localized vesicular oral syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a throat culture for group A Streptococcus is inappropriate because group A streptococcal pharyngitis typically causes tonsillar erythema or exudates rather than diffuse gingivitis and grouped oral vesicles."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Culture an oral lesion for Streptobacillus moniliformis is inappropriate because rat-bite fever is not suggested by this localized vesicular oral syndrome."
            },
            {
              "id": "B",
              "text": "Option A: Measure antinuclear antibody levels is inappropriate because autoimmune testing is not indicated for an acute febrile vesicular oral eruption."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a throat culture for group A Streptococcus is inappropriate because group A streptococcal pharyngitis typically causes tonsillar erythema or exudates rather than diffuse gingivitis and grouped oral vesicles."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Culture an oral lesion for Streptobacillus moniliformis is inappropriate because rat-bite fever is not suggested by this localized vesicular oral syndrome."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide supportive care without further diagnostic testing is inappropriate because supportive care is important, but lesion testing is appropriate when confirming this first episode of suspected HSV infection."
            },
            {
              "id": "B",
              "text": "Option A: Measure antinuclear antibody levels is inappropriate because autoimmune testing is not indicated for an acute febrile vesicular oral eruption."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a throat culture for group A Streptococcus is inappropriate because group A streptococcal pharyngitis typically causes tonsillar erythema or exudates rather than diffuse gingivitis and grouped oral vesicles."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide supportive care without further diagnostic testing is inappropriate because supportive care is important, but lesion testing is appropriate when confirming this first episode of suspected HSV infection."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain serum HSV-1 and HSV-2 IgG antibody levels is inappropriate because type-specific serology indicates prior HSV exposure and may be negative early in a primary infection; it does not directly establish that HSV is causing the active oral lesions. Lesion NAAT is the preferred direct test."
            },
            {
              "id": "B",
              "text": "Option A: Measure antinuclear antibody levels is inappropriate because autoimmune testing is not indicated for an acute febrile vesicular oral eruption."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a throat culture for group A Streptococcus is inappropriate because group A streptococcal pharyngitis typically causes tonsillar erythema or exudates rather than diffuse gingivitis and grouped oral vesicles."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain serum HSV-1 and HSV-2 IgG antibody levels is inappropriate because type-specific serology indicates prior HSV exposure and may be negative early in a primary infection; it does not directly establish that HSV is causing the active oral lesions. Lesion NAAT is the preferred direct test."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform HSV nucleic acid testing on blood rather than on a lesion is inappropriate because blood HSV PCR is used when disseminated or systemic HSV infection is suspected, not to diagnose localized mucocutaneous disease. An active lesion provides the appropriate specimen."
            },
            {
              "id": "B",
              "text": "Option A: Measure antinuclear antibody levels is inappropriate because autoimmune testing is not indicated for an acute febrile vesicular oral eruption."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a throat culture for group A Streptococcus is inappropriate because group A streptococcal pharyngitis typically causes tonsillar erythema or exudates rather than diffuse gingivitis and grouped oral vesicles."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform HSV nucleic acid testing on blood rather than on a lesion is inappropriate because blood HSV PCR is used when disseminated or systemic HSV infection is suspected, not to diagnose localized mucocutaneous disease. An active lesion provides the appropriate specimen."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i016-malignant-pericardial-effusion",
      "expectedHashes": {
        "ranaze_step3_uat": "ef08cec46cec1892e011e0035f2d4ddf39050a951734d93f7b173b023a6c1476",
        "ranaze_step3_prd": "ef08cec46cec1892e011e0035f2d4ddf39050a951734d93f7b173b023a6c1476"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "B",
              "text": "Option C: Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option D: Emotional stress during an acute illness is inappropriate because stress does not account for the structural thoracic findings and progressive constitutional symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            },
            {
              "id": "B",
              "text": "Option B: Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option D: Emotional stress during an acute illness is inappropriate because stress does not account for the structural thoracic findings and progressive constitutional symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Emotional stress during an acute illness is inappropriate because stress does not account for the structural thoracic findings and progressive constitutional symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option C: Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Emotional stress during an acute illness is inappropriate because stress does not account for the structural thoracic findings and progressive constitutional symptoms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recent long-distance travel is inappropriate because travel history alone does not explain the lung mass and malignant-appearing systemic syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option C: Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recent long-distance travel is inappropriate because travel history alone does not explain the lung mass and malignant-appearing systemic syndrome."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Idiopathic viral pericarditis is inappropriate because viral or idiopathic pericarditis can cause pleuritic pain and diffuse ST elevation, but the large effusion plus a 6-cm hilar mass, mediastinal lymphadenopathy, smoking history, cough, and weight loss make malignant pericardial involvement far more likely."
            },
            {
              "id": "B",
              "text": "Option B: Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option C: Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Idiopathic viral pericarditis is inappropriate because viral or idiopathic pericarditis can cause pleuritic pain and diffuse ST elevation, but the large effusion plus a 6-cm hilar mass, mediastinal lymphadenopathy, smoking history, cough, and weight loss make malignant pericardial involvement far more likely."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tuberculous pericarditis can produce a large effusion, but the stem supplies no tuberculosis exposure or compatible pulmonary pattern. A dominant hilar lung mass with mediastinal nodes and marked smoking history instead supports lung cancer."
            },
            {
              "id": "B",
              "text": "Option B: Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option C: Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tuberculous pericarditis can produce a large effusion, but the stem supplies no tuberculosis exposure or compatible pulmonary pattern. A dominant hilar lung mass with mediastinal nodes and marked smoking history instead supports lung cancer."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Uremic pericarditis is inappropriate because uremia is a recognized cause of pericarditis and effusion, but there is no renal history or laboratory evidence of renal failure. It does not explain the lung mass, lymphadenopathy, cough, and weight loss."
            },
            {
              "id": "B",
              "text": "Option B: Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option C: Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Uremic pericarditis is inappropriate because uremia is a recognized cause of pericarditis and effusion, but there is no renal history or laboratory evidence of renal failure. It does not explain the lung mass, lymphadenopathy, cough, and weight loss."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hypothyroidism causing a noninflammatory pericardial effusion is inappropriate because hypothyroidism can cause a slowly accumulating effusion, but it usually lacks acute inflammatory ECG findings and does not explain the thoracic mass or malignant constitutional syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option C: Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hypothyroidism causing a noninflammatory pericardial effusion is inappropriate because hypothyroidism can cause a slowly accumulating effusion, but it usually lacks acute inflammatory ECG findings and does not explain the thoracic mass or malignant constitutional syndrome."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Systemic lupus erythematosus\u2013associated pericarditis is inappropriate because lupus can cause pericarditis, but no systemic autoimmune manifestations are provided. The large hilar mass, mediastinal adenopathy, smoking exposure, and weight loss directly favor malignancy."
            },
            {
              "id": "B",
              "text": "Option B: Acute adverse effect of an antihypertensive medication is inappropriate because medication effects do not explain the lung mass, constitutional symptoms, and large pericardial effusion."
            },
            {
              "id": "C",
              "text": "Option C: Diabetic autonomic neuropathy does not cause inflammatory ECG changes or a large pericardial effusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Systemic lupus erythematosus\u2013associated pericarditis is inappropriate because lupus can cause pericarditis, but no systemic autoimmune manifestations are provided. The large hilar mass, mediastinal adenopathy, smoking exposure, and weight loss directly favor malignancy."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i017-combined-av-nodal-blockade",
      "expectedHashes": {
        "ranaze_step3_uat": "852f76610fca1ca9103d5003dac2401e9510b20feadee2d44bf3d73a9d7c2fbe",
        "ranaze_step3_prd": "852f76610fca1ca9103d5003dac2401e9510b20feadee2d44bf3d73a9d7c2fbe"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Drug-induced reduction in myocardial contractility alone is inappropriate because isolated negative inotropy would not explain complete AV block with a junctional escape rhythm."
            },
            {
              "id": "B",
              "text": "Option C: Additive vasodilation causing isolated hypotension is inappropriate because vasodilation may lower blood pressure but does not produce complete AV block."
            },
            {
              "id": "C",
              "text": "Option D: Hypersensitivity of the carotid sinus reflex is inappropriate because carotid sinus hypersensitivity does not explain the medication timing and documented complete AV block."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Drug-induced reduction in myocardial contractility alone is inappropriate because isolated negative inotropy would not explain complete AV block with a junctional escape rhythm."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Additive vasodilation causing isolated hypotension is inappropriate because vasodilation may lower blood pressure but does not produce complete AV block."
            },
            {
              "id": "B",
              "text": "Option B: Drug-induced reduction in myocardial contractility alone is inappropriate because isolated negative inotropy would not explain complete AV block with a junctional escape rhythm."
            },
            {
              "id": "C",
              "text": "Option D: Hypersensitivity of the carotid sinus reflex is inappropriate because carotid sinus hypersensitivity does not explain the medication timing and documented complete AV block."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Additive vasodilation causing isolated hypotension is inappropriate because vasodilation may lower blood pressure but does not produce complete AV block."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hypersensitivity of the carotid sinus reflex is inappropriate because carotid sinus hypersensitivity does not explain the medication timing and documented complete AV block."
            },
            {
              "id": "B",
              "text": "Option B: Drug-induced reduction in myocardial contractility alone is inappropriate because isolated negative inotropy would not explain complete AV block with a junctional escape rhythm."
            },
            {
              "id": "C",
              "text": "Option C: Additive vasodilation causing isolated hypotension is inappropriate because vasodilation may lower blood pressure but does not produce complete AV block."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hypersensitivity of the carotid sinus reflex is inappropriate because carotid sinus hypersensitivity does not explain the medication timing and documented complete AV block."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neurocardiogenic syncope generally causes transient reflex hypotension and bradycardia, not persistent complete AV block."
            },
            {
              "id": "B",
              "text": "Option B: Drug-induced reduction in myocardial contractility alone is inappropriate because isolated negative inotropy would not explain complete AV block with a junctional escape rhythm."
            },
            {
              "id": "C",
              "text": "Option C: Additive vasodilation causing isolated hypotension is inappropriate because vasodilation may lower blood pressure but does not produce complete AV block."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neurocardiogenic syncope generally causes transient reflex hypotension and bradycardia, not persistent complete AV block."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sinus-node dysfunction causing failure of impulse generation is inappropriate because sinus-node dysfunction causes inappropriate sinus bradycardia, pauses, or sinus arrest. The ECG instead explicitly identifies complete AV block, meaning atrial impulses are generated but fail to conduct."
            },
            {
              "id": "B",
              "text": "Option B: Drug-induced reduction in myocardial contractility alone is inappropriate because isolated negative inotropy would not explain complete AV block with a junctional escape rhythm."
            },
            {
              "id": "C",
              "text": "Option C: Additive vasodilation causing isolated hypotension is inappropriate because vasodilation may lower blood pressure but does not produce complete AV block."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sinus-node dysfunction causing failure of impulse generation is inappropriate because sinus-node dysfunction causes inappropriate sinus bradycardia, pauses, or sinus arrest. The ECG instead explicitly identifies complete AV block, meaning atrial impulses are generated but fail to conduct."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i018-ruptured-ectopic-pregnancy",
      "expectedHashes": {
        "ranaze_step3_uat": "cf0e587de007fcd0248485244ee382d07e3e280ce3885bed2307857322dca9c3",
        "ranaze_step3_prd": "cf0e587de007fcd0248485244ee382d07e3e280ce3885bed2307857322dca9c3"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A positive home pregnancy test is inappropriate because a positive pregnancy test establishes pregnancy but does not by itself determine the need for surgery."
            },
            {
              "id": "B",
              "text": "Option C: Light vaginal spotting for 4 days is inappropriate because vaginal spotting is common in ectopic pregnancy but does not alone establish the need for surgery."
            },
            {
              "id": "C",
              "text": "Option D: A remote history of treated pelvic inflammatory disease is inappropriate because prior pelvic inflammatory disease increases ectopic pregnancy risk but is not an indication for emergency surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A positive home pregnancy test is inappropriate because a positive pregnancy test establishes pregnancy but does not by itself determine the need for surgery."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Light vaginal spotting for 4 days is inappropriate because vaginal spotting is common in ectopic pregnancy but does not alone establish the need for surgery."
            },
            {
              "id": "B",
              "text": "Option A: A positive home pregnancy test is inappropriate because a positive pregnancy test establishes pregnancy but does not by itself determine the need for surgery."
            },
            {
              "id": "C",
              "text": "Option D: A remote history of treated pelvic inflammatory disease is inappropriate because prior pelvic inflammatory disease increases ectopic pregnancy risk but is not an indication for emergency surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Light vaginal spotting for 4 days is inappropriate because vaginal spotting is common in ectopic pregnancy but does not alone establish the need for surgery."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A remote history of treated pelvic inflammatory disease is inappropriate because prior pelvic inflammatory disease increases ectopic pregnancy risk but is not an indication for emergency surgery."
            },
            {
              "id": "B",
              "text": "Option A: A positive home pregnancy test is inappropriate because a positive pregnancy test establishes pregnancy but does not by itself determine the need for surgery."
            },
            {
              "id": "C",
              "text": "Option C: Light vaginal spotting for 4 days is inappropriate because vaginal spotting is common in ectopic pregnancy but does not alone establish the need for surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A remote history of treated pelvic inflammatory disease is inappropriate because prior pelvic inflammatory disease increases ectopic pregnancy risk but is not an indication for emergency surgery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Right-sided pelvic pain is inappropriate because pelvic pain is nonspecific and does not alone distinguish patients who need urgent operative treatment."
            },
            {
              "id": "B",
              "text": "Option A: A positive home pregnancy test is inappropriate because a positive pregnancy test establishes pregnancy but does not by itself determine the need for surgery."
            },
            {
              "id": "C",
              "text": "Option C: Light vaginal spotting for 4 days is inappropriate because vaginal spotting is common in ectopic pregnancy but does not alone establish the need for surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Right-sided pelvic pain is inappropriate because pelvic pain is nonspecific and does not alone distinguish patients who need urgent operative treatment."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An empty uterus 7 weeks after the last menstrual period is inappropriate because an empty uterus at the reported gestational age raises concern for ectopic pregnancy or pregnancy loss, but it does not alone mandate immediate surgery. Persistent shock with an adnexal mass and free fluid does."
            },
            {
              "id": "B",
              "text": "Option A: A positive home pregnancy test is inappropriate because a positive pregnancy test establishes pregnancy but does not by itself determine the need for surgery."
            },
            {
              "id": "C",
              "text": "Option C: Light vaginal spotting for 4 days is inappropriate because vaginal spotting is common in ectopic pregnancy but does not alone establish the need for surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An empty uterus 7 weeks after the last menstrual period is inappropriate because an empty uterus at the reported gestational age raises concern for ectopic pregnancy or pregnancy loss, but it does not alone mandate immediate surgery. Persistent shock with an adnexal mass and free fluid does."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i019-prenatal-cf-testing",
      "expectedHashes": {
        "ranaze_step3_uat": "627d2d10a0456600283998c8351e000cef2743982f5470b3405ca060c2d9dbb8",
        "ranaze_step3_prd": "627d2d10a0456600283998c8351e000cef2743982f5470b3405ca060c2d9dbb8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Because the disorder is autosomal recessive, each future fetus has a 50% chance of being affected is inappropriate because each pregnancy has a 25%, not 50%, chance of producing an affected child."
            },
            {
              "id": "B",
              "text": "Option C: Prenatal testing is accurate only when the affected child has the F508del variant is inappropriate because prenatal testing can target any identified pathogenic CFTR variants; it is not limited to F508del."
            },
            {
              "id": "C",
              "text": "Option D: The absence of cystic fibrosis symptoms in both parents excludes recurrence in future children is inappropriate because carriers are typically asymptomatic, so parental health does not exclude recurrence risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Because the disorder is autosomal recessive, each future fetus has a 50% chance of being affected is inappropriate because each pregnancy has a 25%, not 50%, chance of producing an affected child."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prenatal testing is accurate only when the affected child has the F508del variant is inappropriate because prenatal testing can target any identified pathogenic CFTR variants; it is not limited to F508del."
            },
            {
              "id": "B",
              "text": "Option A: Because the disorder is autosomal recessive, each future fetus has a 50% chance of being affected is inappropriate because each pregnancy has a 25%, not 50%, chance of producing an affected child."
            },
            {
              "id": "C",
              "text": "Option D: The absence of cystic fibrosis symptoms in both parents excludes recurrence in future children is inappropriate because carriers are typically asymptomatic, so parental health does not exclude recurrence risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prenatal testing is accurate only when the affected child has the F508del variant is inappropriate because prenatal testing can target any identified pathogenic CFTR variants; it is not limited to F508del."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The absence of cystic fibrosis symptoms in both parents excludes recurrence in future children is inappropriate because carriers are typically asymptomatic, so parental health does not exclude recurrence risk."
            },
            {
              "id": "B",
              "text": "Option A: Because the disorder is autosomal recessive, each future fetus has a 50% chance of being affected is inappropriate because each pregnancy has a 25%, not 50%, chance of producing an affected child."
            },
            {
              "id": "C",
              "text": "Option C: Prenatal testing is accurate only when the affected child has the F508del variant is inappropriate because prenatal testing can target any identified pathogenic CFTR variants; it is not limited to F508del."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The absence of cystic fibrosis symptoms in both parents excludes recurrence in future children is inappropriate because carriers are typically asymptomatic, so parental health does not exclude recurrence risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cystic fibrosis in their daughter most likely resulted from a new mutation, so future children are not at increased risk is inappropriate because cystic fibrosis is usually inherited in an autosomal-recessive pattern, not due to a de novo mutation."
            },
            {
              "id": "B",
              "text": "Option A: Because the disorder is autosomal recessive, each future fetus has a 50% chance of being affected is inappropriate because each pregnancy has a 25%, not 50%, chance of producing an affected child."
            },
            {
              "id": "C",
              "text": "Option C: Prenatal testing is accurate only when the affected child has the F508del variant is inappropriate because prenatal testing can target any identified pathogenic CFTR variants; it is not limited to F508del."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cystic fibrosis in their daughter most likely resulted from a new mutation, so future children are not at increased risk is inappropriate because cystic fibrosis is usually inherited in an autosomal-recessive pattern, not due to a de novo mutation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Only maternal CFTR testing is needed because the mother\u0027s genotype determines fetal disease status is inappropriate because cF is autosomal recessive. Fetal disease requires inheritance of a pathogenic variant from each carrier parent, so both parental familial variants matter."
            },
            {
              "id": "B",
              "text": "Option A: Because the disorder is autosomal recessive, each future fetus has a 50% chance of being affected is inappropriate because each pregnancy has a 25%, not 50%, chance of producing an affected child."
            },
            {
              "id": "C",
              "text": "Option C: Prenatal testing is accurate only when the affected child has the F508del variant is inappropriate because prenatal testing can target any identified pathogenic CFTR variants; it is not limited to F508del."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Only maternal CFTR testing is needed because the mother\u0027s genotype determines fetal disease status is inappropriate because cF is autosomal recessive. Fetal disease requires inheritance of a pathogenic variant from each carrier parent, so both parental familial variants matter."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Each future fetus has a 75% chance of having cystic fibrosis because 3 of the 4 possible parental allele combinations contain a pathogenic variant is inappropriate because three of four allele combinations contain at least one pathogenic variant, but two of those produce unaffected carriers. Only the one combination inheriting both variants causes CF, giving a 25% affected risk."
            },
            {
              "id": "B",
              "text": "Option A: Because the disorder is autosomal recessive, each future fetus has a 50% chance of being affected is inappropriate because each pregnancy has a 25%, not 50%, chance of producing an affected child."
            },
            {
              "id": "C",
              "text": "Option C: Prenatal testing is accurate only when the affected child has the F508del variant is inappropriate because prenatal testing can target any identified pathogenic CFTR variants; it is not limited to F508del."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Each future fetus has a 75% chance of having cystic fibrosis because 3 of the 4 possible parental allele combinations contain a pathogenic variant is inappropriate because three of four allele combinations contain at least one pathogenic variant, but two of those produce unaffected carriers. Only the one combination inheriting both variants causes CF, giving a 25% affected risk."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amniocentesis should test fetal chromosomes rather than the known CFTR variants is inappropriate because a karyotype evaluates chromosome number and large structural abnormalities, not the specific familial CFTR sequence variants. Targeted molecular analysis is the informative test."
            },
            {
              "id": "B",
              "text": "Option A: Because the disorder is autosomal recessive, each future fetus has a 50% chance of being affected is inappropriate because each pregnancy has a 25%, not 50%, chance of producing an affected child."
            },
            {
              "id": "C",
              "text": "Option C: Prenatal testing is accurate only when the affected child has the F508del variant is inappropriate because prenatal testing can target any identified pathogenic CFTR variants; it is not limited to F508del."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amniocentesis should test fetal chromosomes rather than the known CFTR variants is inappropriate because a karyotype evaluates chromosome number and large structural abnormalities, not the specific familial CFTR sequence variants. Targeted molecular analysis is the informative test."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i020-prematurity-cerebral-palsy",
      "expectedHashes": {
        "ranaze_step3_uat": "97de6bf0ecd2b1f148532924a633598cdc6fc26bb40965961caeb97fad01ccc2",
        "ranaze_step3_prd": "97de6bf0ecd2b1f148532924a633598cdc6fc26bb40965961caeb97fad01ccc2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Birth weight of 1.35 kg is inappropriate because low birth weight is associated with risk but largely overlaps with the stronger risk factor of prematurity."
            },
            {
              "id": "B",
              "text": "Option C: Brief need for positive-pressure ventilation is inappropriate because a brief period of resuscitation with a normal 5-minute Apgar score is less predictive than prematurity."
            },
            {
              "id": "C",
              "text": "Option D: Maternal cigarette use during pregnancy is inappropriate because smoking has adverse pregnancy effects but is not the strongest listed predictor of cerebral palsy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Birth weight of 1.35 kg is inappropriate because low birth weight is associated with risk but largely overlaps with the stronger risk factor of prematurity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Brief need for positive-pressure ventilation is inappropriate because a brief period of resuscitation with a normal 5-minute Apgar score is less predictive than prematurity."
            },
            {
              "id": "B",
              "text": "Option B: Birth weight of 1.35 kg is inappropriate because low birth weight is associated with risk but largely overlaps with the stronger risk factor of prematurity."
            },
            {
              "id": "C",
              "text": "Option D: Maternal cigarette use during pregnancy is inappropriate because smoking has adverse pregnancy effects but is not the strongest listed predictor of cerebral palsy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Brief need for positive-pressure ventilation is inappropriate because a brief period of resuscitation with a normal 5-minute Apgar score is less predictive than prematurity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal cigarette use during pregnancy is inappropriate because smoking has adverse pregnancy effects but is not the strongest listed predictor of cerebral palsy."
            },
            {
              "id": "B",
              "text": "Option B: Birth weight of 1.35 kg is inappropriate because low birth weight is associated with risk but largely overlaps with the stronger risk factor of prematurity."
            },
            {
              "id": "C",
              "text": "Option C: Brief need for positive-pressure ventilation is inappropriate because a brief period of resuscitation with a normal 5-minute Apgar score is less predictive than prematurity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal cigarette use during pregnancy is inappropriate because smoking has adverse pregnancy effects but is not the strongest listed predictor of cerebral palsy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inconsistent prenatal visits is inappropriate because limited prenatal care can worsen outcomes but is less strongly associated with cerebral palsy than preterm delivery."
            },
            {
              "id": "B",
              "text": "Option B: Birth weight of 1.35 kg is inappropriate because low birth weight is associated with risk but largely overlaps with the stronger risk factor of prematurity."
            },
            {
              "id": "C",
              "text": "Option C: Brief need for positive-pressure ventilation is inappropriate because a brief period of resuscitation with a normal 5-minute Apgar score is less predictive than prematurity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inconsistent prenatal visits is inappropriate because limited prenatal care can worsen outcomes but is less strongly associated with cerebral palsy than preterm delivery."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i021-emergency-consent",
      "expectedHashes": {
        "ranaze_step3_uat": "b1c115e21249dfc042c036c6a91c608204e9d537d30c40bce531cf61e54ff32b",
        "ranaze_step3_prd": "b1c115e21249dfc042c036c6a91c608204e9d537d30c40bce531cf61e54ff32b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay evaluation until a parent can provide telephone consent is inappropriate because delaying care is inappropriate when airway compromise is possible."
            },
            {
              "id": "B",
              "text": "Option B: Obtain consent from the adult cousin before examining the patient is inappropriate because an adult cousin generally cannot provide legal consent solely by accompanying the minor, and urgent care should not wait."
            },
            {
              "id": "C",
              "text": "Option C: Ask the adolescent to give legally sufficient consent for all care is inappropriate because most unemancipated minors cannot independently provide broad legal consent, although their assent should be sought when possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay evaluation until a parent can provide telephone consent is inappropriate because delaying care is inappropriate when airway compromise is possible."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain consent from the adult cousin before examining the patient is inappropriate because an adult cousin generally cannot provide legal consent solely by accompanying the minor, and urgent care should not wait."
            },
            {
              "id": "B",
              "text": "Option A: Delay evaluation until a parent can provide telephone consent is inappropriate because delaying care is inappropriate when airway compromise is possible."
            },
            {
              "id": "C",
              "text": "Option C: Ask the adolescent to give legally sufficient consent for all care is inappropriate because most unemancipated minors cannot independently provide broad legal consent, although their assent should be sought when possible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain consent from the adult cousin before examining the patient is inappropriate because an adult cousin generally cannot provide legal consent solely by accompanying the minor, and urgent care should not wait."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the adolescent to give legally sufficient consent for all care is inappropriate because most unemancipated minors cannot independently provide broad legal consent, although their assent should be sought when possible."
            },
            {
              "id": "B",
              "text": "Option A: Delay evaluation until a parent can provide telephone consent is inappropriate because delaying care is inappropriate when airway compromise is possible."
            },
            {
              "id": "C",
              "text": "Option B: Obtain consent from the adult cousin before examining the patient is inappropriate because an adult cousin generally cannot provide legal consent solely by accompanying the minor, and urgent care should not wait."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the adolescent to give legally sufficient consent for all care is inappropriate because most unemancipated minors cannot independently provide broad legal consent, although their assent should be sought when possible."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contact the hospital legal department before performing an airway assessment is inappropriate because legal consultation should not delay urgent assessment of a potentially threatened airway."
            },
            {
              "id": "B",
              "text": "Option A: Delay evaluation until a parent can provide telephone consent is inappropriate because delaying care is inappropriate when airway compromise is possible."
            },
            {
              "id": "C",
              "text": "Option B: Obtain consent from the adult cousin before examining the patient is inappropriate because an adult cousin generally cannot provide legal consent solely by accompanying the minor, and urgent care should not wait."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contact the hospital legal department before performing an airway assessment is inappropriate because legal consultation should not delay urgent assessment of a potentially threatened airway."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Examine the posterior pharynx with a tongue depressor before arranging airway support is inappropriate because drooling, muffled speech, inspiratory noise, fever, and upright positioning suggest epiglottitis with threatened obstruction. Instrumenting the pharynx outside a controlled airway setting can precipitate complete obstruction and must not precede stabilization."
            },
            {
              "id": "B",
              "text": "Option A: Delay evaluation until a parent can provide telephone consent is inappropriate because delaying care is inappropriate when airway compromise is possible."
            },
            {
              "id": "C",
              "text": "Option B: Obtain consent from the adult cousin before examining the patient is inappropriate because an adult cousin generally cannot provide legal consent solely by accompanying the minor, and urgent care should not wait."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Examine the posterior pharynx with a tongue depressor before arranging airway support is inappropriate because drooling, muffled speech, inspiratory noise, fever, and upright positioning suggest epiglottitis with threatened obstruction. Instrumenting the pharynx outside a controlled airway setting can precipitate complete obstruction and must not precede stabilization."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a lateral neck radiograph before beginning airway stabilization is inappropriate because imaging may assist when suspicion is low and the patient is stable, but this patient has signs of impending obstruction. Transporting or positioning him for radiography before airway stabilization creates an unsafe delay."
            },
            {
              "id": "B",
              "text": "Option A: Delay evaluation until a parent can provide telephone consent is inappropriate because delaying care is inappropriate when airway compromise is possible."
            },
            {
              "id": "C",
              "text": "Option B: Obtain consent from the adult cousin before examining the patient is inappropriate because an adult cousin generally cannot provide legal consent solely by accompanying the minor, and urgent care should not wait."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a lateral neck radiograph before beginning airway stabilization is inappropriate because imaging may assist when suspicion is low and the patient is stable, but this patient has signs of impending obstruction. Transporting or positioning him for radiography before airway stabilization creates an unsafe delay."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous ceftriaxone before securing or stabilizing the airway is inappropriate because a beta-lactamase-resistant intravenous antibiotic such as ceftriaxone is appropriate after the airway is addressed in suspected bacterial epiglottitis. Giving antibiotics before airway stabilization is a sequencing error because airway management is paramount."
            },
            {
              "id": "B",
              "text": "Option A: Delay evaluation until a parent can provide telephone consent is inappropriate because delaying care is inappropriate when airway compromise is possible."
            },
            {
              "id": "C",
              "text": "Option B: Obtain consent from the adult cousin before examining the patient is inappropriate because an adult cousin generally cannot provide legal consent solely by accompanying the minor, and urgent care should not wait."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous ceftriaxone before securing or stabilizing the airway is inappropriate because a beta-lactamase-resistant intravenous antibiotic such as ceftriaxone is appropriate after the airway is addressed in suspected bacterial epiglottitis. Giving antibiotics before airway stabilization is a sequencing error because airway management is paramount."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i022-burn-tetanus-history",
      "expectedHashes": {
        "ranaze_step3_uat": "0ec028e7e1809719e57397ad0a72b2a38806b11b9d672214603629652c80b59c",
        "ranaze_step3_prd": "0ec028e7e1809719e57397ad0a72b2a38806b11b9d672214603629652c80b59c"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "B",
              "text": "Option B: History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            },
            {
              "id": "C",
              "text": "Option D: History of attention-deficit/hyperactivity disorder in relatives is inappropriate because family ADHD history is unrelated to acute burn management."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            },
            {
              "id": "B",
              "text": "Option A: History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "C",
              "text": "Option D: History of attention-deficit/hyperactivity disorder in relatives is inappropriate because family ADHD history is unrelated to acute burn management."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "History of attention-deficit/hyperactivity disorder in relatives is inappropriate because family ADHD history is unrelated to acute burn management."
            },
            {
              "id": "B",
              "text": "Option A: History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "C",
              "text": "Option B: History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "History of attention-deficit/hyperactivity disorder in relatives is inappropriate because family ADHD history is unrelated to acute burn management."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prior percentile for height is inappropriate because linear growth history does not guide acute management of this burn."
            },
            {
              "id": "B",
              "text": "Option A: History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "C",
              "text": "Option B: History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prior percentile for height is inappropriate because linear growth history does not guide acute management of this burn."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Time of her last solid-food intake is inappropriate because last oral intake could become relevant if procedural sedation were planned, but this small isolated burn does not yet establish that need. The uncertain vaccine record immediately affects tetanus prophylaxis."
            },
            {
              "id": "B",
              "text": "Option A: History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "C",
              "text": "Option B: History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Time of her last solid-food intake is inappropriate because last oral intake could become relevant if procedural sedation were planned, but this small isolated burn does not yet establish that need. The uncertain vaccine record immediately affects tetanus prophylaxis."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "History of medication allergies is inappropriate because medication allergies are part of a general history and may matter before analgesic or antimicrobial use, but no such treatment decision supersedes determining tetanus immunization status after a burn."
            },
            {
              "id": "B",
              "text": "Option A: History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "C",
              "text": "Option B: History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "History of medication allergies is inappropriate because medication allergies are part of a general history and may matter before analgesic or antimicrobial use, but no such treatment decision supersedes determining tetanus immunization status after a burn."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the left hand is her dominant hand is inappropriate because hand dominance can help anticipate functional impact and rehabilitation needs, but it does not guide the immediate prophylaxis decision created by the uncertain vaccination history."
            },
            {
              "id": "B",
              "text": "Option A: History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "C",
              "text": "Option B: History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the left hand is her dominant hand is inappropriate because hand dominance can help anticipate functional impact and rehabilitation needs, but it does not guide the immediate prophylaxis decision created by the uncertain vaccination history."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "History of previous accidental burns is inappropriate because prior injuries can contribute to a broader safety assessment, but this injury has a coherent witnessed mechanism and prompt first aid. Vaccine completion and timing directly determine tetanus prophylaxis."
            },
            {
              "id": "B",
              "text": "Option A: History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "C",
              "text": "Option B: History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "History of previous accidental burns is inappropriate because prior injuries can contribute to a broader safety assessment, but this injury has a coherent witnessed mechanism and prompt first aid. Vaccine completion and timing directly determine tetanus prophylaxis."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether butter, ointment, or another substance was applied before arrival is inappropriate because prearrival topical substances may affect wound cleansing, but the stem already describes appropriate immediate cooling. The unresolved tetanus-containing vaccine history is more important because burns are tetanus-prone wounds."
            },
            {
              "id": "B",
              "text": "Option A: History of seasonal allergic rhinitis is inappropriate because allergic rhinitis history does not affect immediate burn prophylaxis."
            },
            {
              "id": "C",
              "text": "Option B: History of recurrent skin abscesses is inappropriate because a history of skin abscesses is not the key additional history for this acute thermal injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether butter, ointment, or another substance was applied before arrival is inappropriate because prearrival topical substances may affect wound cleansing, but the stem already describes appropriate immediate cooling. The unresolved tetanus-containing vaccine history is more important because burns are tetanus-prone wounds."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i025-iron-deficiency-pica",
      "expectedHashes": {
        "ranaze_step3_uat": "b50b8d43f2c9d7ba8c5f1670ff73cb558356829914e46846cb03bed191a1c174",
        "ranaze_step3_prd": "b50b8d43f2c9d7ba8c5f1670ff73cb558356829914e46846cb03bed191a1c174"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exertional palpitations can occur with anemia but do not specifically identify iron deficiency."
            },
            {
              "id": "B",
              "text": "Option B: Remote tobacco use does not explain her microcytic anemia with low ferritin."
            },
            {
              "id": "C",
              "text": "Option D: Absence of blood on urinalysis is inappropriate because a urinalysis without blood does not establish the cause of iron deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exertional palpitations can occur with anemia but do not specifically identify iron deficiency."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remote tobacco use does not explain her microcytic anemia with low ferritin."
            },
            {
              "id": "B",
              "text": "Option A: Exertional palpitations can occur with anemia but do not specifically identify iron deficiency."
            },
            {
              "id": "C",
              "text": "Option D: Absence of blood on urinalysis is inappropriate because a urinalysis without blood does not establish the cause of iron deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remote tobacco use does not explain her microcytic anemia with low ferritin."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Absence of blood on urinalysis is inappropriate because a urinalysis without blood does not establish the cause of iron deficiency."
            },
            {
              "id": "B",
              "text": "Option A: Exertional palpitations can occur with anemia but do not specifically identify iron deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Remote tobacco use does not explain her microcytic anemia with low ferritin."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Absence of blood on urinalysis is inappropriate because a urinalysis without blood does not establish the cause of iron deficiency."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gardening-related fatigue is inappropriate because fatigue while gardening is nonspecific and can result from anemia of many causes."
            },
            {
              "id": "B",
              "text": "Option A: Exertional palpitations can occur with anemia but do not specifically identify iron deficiency."
            },
            {
              "id": "C",
              "text": "Option B: Remote tobacco use does not explain her microcytic anemia with low ferritin."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gardening-related fatigue is inappropriate because fatigue while gardening is nonspecific and can result from anemia of many causes."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i026-uncontrolled-clinical-trial",
      "expectedHashes": {
        "ranaze_step3_uat": "c5b04212e6661eb5b6de2559261d7f34ad627db46cc86fd9802ce2acd12ee85c",
        "ranaze_step3_prd": "c5b04212e6661eb5b6de2559261d7f34ad627db46cc86fd9802ce2acd12ee85c"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The report is invalid because it does not use approved scientific methods. is inappropriate because the study has major limitations, but it is more accurate to explain that its design cannot determine treatment efficacy."
            },
            {
              "id": "B",
              "text": "Option B: The reported blood-pressure reduction proves the supplement is effective. is inappropriate because a decrease after treatment in an uncontrolled group does not prove causation."
            },
            {
              "id": "C",
              "text": "Option C: The report should be ignored because supplements cannot affect blood pressure. is inappropriate because supplements can have physiologic effects; the issue is inadequate evidence, not impossibility."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The report is invalid because it does not use approved scientific methods. is inappropriate because the study has major limitations, but it is more accurate to explain that its design cannot determine treatment efficacy."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The reported blood-pressure reduction proves the supplement is effective. is inappropriate because a decrease after treatment in an uncontrolled group does not prove causation."
            },
            {
              "id": "B",
              "text": "Option A: The report is invalid because it does not use approved scientific methods. is inappropriate because the study has major limitations, but it is more accurate to explain that its design cannot determine treatment efficacy."
            },
            {
              "id": "C",
              "text": "Option C: The report should be ignored because supplements cannot affect blood pressure. is inappropriate because supplements can have physiologic effects; the issue is inadequate evidence, not impossibility."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The reported blood-pressure reduction proves the supplement is effective. is inappropriate because a decrease after treatment in an uncontrolled group does not prove causation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The report should be ignored because supplements cannot affect blood pressure. is inappropriate because supplements can have physiologic effects; the issue is inadequate evidence, not impossibility."
            },
            {
              "id": "B",
              "text": "Option A: The report is invalid because it does not use approved scientific methods. is inappropriate because the study has major limitations, but it is more accurate to explain that its design cannot determine treatment efficacy."
            },
            {
              "id": "C",
              "text": "Option B: The reported blood-pressure reduction proves the supplement is effective. is inappropriate because a decrease after treatment in an uncontrolled group does not prove causation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The report should be ignored because supplements cannot affect blood pressure. is inappropriate because supplements can have physiologic effects; the issue is inadequate evidence, not impossibility."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lack of random assignment alone makes the report entirely useless. is inappropriate because nonrandomized evidence can be hypothesis-generating; multiple design limitations prevent a treatment conclusion."
            },
            {
              "id": "B",
              "text": "Option A: The report is invalid because it does not use approved scientific methods. is inappropriate because the study has major limitations, but it is more accurate to explain that its design cannot determine treatment efficacy."
            },
            {
              "id": "C",
              "text": "Option B: The reported blood-pressure reduction proves the supplement is effective. is inappropriate because a decrease after treatment in an uncontrolled group does not prove causation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lack of random assignment alone makes the report entirely useless. is inappropriate because nonrandomized evidence can be hypothesis-generating; multiple design limitations prevent a treatment conclusion."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The absence of reported adverse effects establishes that the supplement is safe is inappropriate because failure to describe adverse effects is not evidence that none occurred. Six participants followed for only 4 weeks are also insufficient to establish safety or detect uncommon or delayed harms."
            },
            {
              "id": "B",
              "text": "Option A: The report is invalid because it does not use approved scientific methods. is inappropriate because the study has major limitations, but it is more accurate to explain that its design cannot determine treatment efficacy."
            },
            {
              "id": "C",
              "text": "Option B: The reported blood-pressure reduction proves the supplement is effective. is inappropriate because a decrease after treatment in an uncontrolled group does not prove causation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The absence of reported adverse effects establishes that the supplement is safe is inappropriate because failure to describe adverse effects is not evidence that none occurred. Six participants followed for only 4 weeks are also insufficient to establish safety or detect uncommon or delayed harms."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Calculate a P value for the before-and-after blood-pressure change to determine whether the supplement works is inappropriate because statistical significance cannot remedy the absence of a comparison group or establish causation. The report also provides only an average endpoint, not the participant-level data needed for a valid paired analysis."
            },
            {
              "id": "B",
              "text": "Option A: The report is invalid because it does not use approved scientific methods. is inappropriate because the study has major limitations, but it is more accurate to explain that its design cannot determine treatment efficacy."
            },
            {
              "id": "C",
              "text": "Option B: The reported blood-pressure reduction proves the supplement is effective. is inappropriate because a decrease after treatment in an uncontrolled group does not prove causation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Calculate a P value for the before-and-after blood-pressure change to determine whether the supplement works is inappropriate because statistical significance cannot remedy the absence of a comparison group or establish causation. The report also provides only an average endpoint, not the participant-level data needed for a valid paired analysis."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The report can be treated as confirmatory because a commercially available botanical supplement must already have passed regulatory efficacy review is inappropriate because commercial availability does not establish efficacy. Dietary supplements, including botanical supplements, generally do not undergo FDA premarket approval for safety or effectiveness; therefore, marketing the product does not strengthen the causal inference from this six-person uncontrolled report."
            },
            {
              "id": "B",
              "text": "Option A: The report is invalid because it does not use approved scientific methods. is inappropriate because the study has major limitations, but it is more accurate to explain that its design cannot determine treatment efficacy."
            },
            {
              "id": "C",
              "text": "Option B: The reported blood-pressure reduction proves the supplement is effective. is inappropriate because a decrease after treatment in an uncontrolled group does not prove causation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The report can be treated as confirmatory because a commercially available botanical supplement must already have passed regulatory efficacy review is inappropriate because commercial availability does not establish efficacy. Dietary supplements, including botanical supplements, generally do not undergo FDA premarket approval for safety or effectiveness; therefore, marketing the product does not strengthen the causal inference from this six-person uncontrolled report."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i027-hypertension-medication-adherence",
      "expectedHashes": {
        "ranaze_step3_uat": "c44ebb480f5021409388584905539c2229bc60f0c6ee8dd7d49b70ab859d1a8e",
        "ranaze_step3_prd": "c44ebb480f5021409388584905539c2229bc60f0c6ee8dd7d49b70ab859d1a8e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend the botanical product and lower the amlodipine dose is inappropriate because the botanical product has not been shown to safely replace antihypertensive therapy, and reducing effective treatment could worsen control."
            },
            {
              "id": "B",
              "text": "Option B: Stop amlodipine and begin the botanical product is inappropriate because stopping a medication that is controlling blood pressure for an unproven supplement is inappropriate."
            },
            {
              "id": "C",
              "text": "Option C: Tell the patient to continue amlodipine for another 2 months without further discussion is inappropriate because simply directing continued treatment does not explore the patient\u0027s concern or possible medication intolerance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend the botanical product and lower the amlodipine dose is inappropriate because the botanical product has not been shown to safely replace antihypertensive therapy, and reducing effective treatment could worsen control."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop amlodipine and begin the botanical product is inappropriate because stopping a medication that is controlling blood pressure for an unproven supplement is inappropriate."
            },
            {
              "id": "B",
              "text": "Option A: Recommend the botanical product and lower the amlodipine dose is inappropriate because the botanical product has not been shown to safely replace antihypertensive therapy, and reducing effective treatment could worsen control."
            },
            {
              "id": "C",
              "text": "Option C: Tell the patient to continue amlodipine for another 2 months without further discussion is inappropriate because simply directing continued treatment does not explore the patient\u0027s concern or possible medication intolerance."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop amlodipine and begin the botanical product is inappropriate because stopping a medication that is controlling blood pressure for an unproven supplement is inappropriate."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tell the patient to continue amlodipine for another 2 months without further discussion is inappropriate because simply directing continued treatment does not explore the patient\u0027s concern or possible medication intolerance."
            },
            {
              "id": "B",
              "text": "Option A: Recommend the botanical product and lower the amlodipine dose is inappropriate because the botanical product has not been shown to safely replace antihypertensive therapy, and reducing effective treatment could worsen control."
            },
            {
              "id": "C",
              "text": "Option B: Stop amlodipine and begin the botanical product is inappropriate because stopping a medication that is controlling blood pressure for an unproven supplement is inappropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tell the patient to continue amlodipine for another 2 months without further discussion is inappropriate because simply directing continued treatment does not explore the patient\u0027s concern or possible medication intolerance."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop amlodipine and recommend sodium restriction alone is inappropriate because dietary sodium reduction is beneficial but should not replace effective medication without a reasoned treatment plan."
            },
            {
              "id": "B",
              "text": "Option A: Recommend the botanical product and lower the amlodipine dose is inappropriate because the botanical product has not been shown to safely replace antihypertensive therapy, and reducing effective treatment could worsen control."
            },
            {
              "id": "C",
              "text": "Option B: Stop amlodipine and begin the botanical product is inappropriate because stopping a medication that is controlling blood pressure for an unproven supplement is inappropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop amlodipine and recommend sodium restriction alone is inappropriate because dietary sodium reduction is beneficial but should not replace effective medication without a reasoned treatment plan."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue amlodipine and add the botanical product to accommodate the patient\u0027s preference is inappropriate because adding an unproven product creates unnecessary exposure to adverse effects and interactions and does not identify why the patient wants to replace effective treatment. The targeted next step is to explore possible amlodipine adverse effects and other adherence concerns."
            },
            {
              "id": "B",
              "text": "Option A: Recommend the botanical product and lower the amlodipine dose is inappropriate because the botanical product has not been shown to safely replace antihypertensive therapy, and reducing effective treatment could worsen control."
            },
            {
              "id": "C",
              "text": "Option B: Stop amlodipine and begin the botanical product is inappropriate because stopping a medication that is controlling blood pressure for an unproven supplement is inappropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue amlodipine and add the botanical product to accommodate the patient\u0027s preference is inappropriate because adding an unproven product creates unnecessary exposure to adverse effects and interactions and does not identify why the patient wants to replace effective treatment. The targeted next step is to explore possible amlodipine adverse effects and other adherence concerns."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop amlodipine, begin home blood-pressure monitoring, and restart it only if hypertension recurs is inappropriate because the normal blood pressure follows initiation of amlodipine and therefore demonstrates treatment response, not resolution of hypertension. Stopping it risks loss of control and does not address the adherence barrier."
            },
            {
              "id": "B",
              "text": "Option A: Recommend the botanical product and lower the amlodipine dose is inappropriate because the botanical product has not been shown to safely replace antihypertensive therapy, and reducing effective treatment could worsen control."
            },
            {
              "id": "C",
              "text": "Option B: Stop amlodipine and begin the botanical product is inappropriate because stopping a medication that is controlling blood pressure for an unproven supplement is inappropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop amlodipine, begin home blood-pressure monitoring, and restart it only if hypertension recurs is inappropriate because the normal blood pressure follows initiation of amlodipine and therefore demonstrates treatment response, not resolution of hypertension. Stopping it risks loss of control and does not address the adherence barrier."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i028-informed-refusal-follow-up",
      "expectedHashes": {
        "ranaze_step3_uat": "5217584aafe2ab1b1a1e2c980af40b7cabce7b87413c8ba002a4f6dc8749866a",
        "ranaze_step3_prd": "5217584aafe2ab1b1a1e2c980af40b7cabce7b87413c8ba002a4f6dc8749866a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "State that the patient must follow the physician\u0027s recommendation to remain in the practice is inappropriate because a competent patient may refuse recommendations; coercion undermines autonomy."
            },
            {
              "id": "B",
              "text": "Option B: End the physician-patient relationship because the patient rejects the recommendation is inappropriate because disagreement over a nonemergent treatment decision does not justify abandoning a patient who needs ongoing care."
            },
            {
              "id": "C",
              "text": "Option D: Tell the patient that use of the capsule is at the patient\u0027s own risk and that the physician has no responsibility is inappropriate because risk disclosure does not eliminate the physician\u0027s duty to provide appropriate ongoing care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "State that the patient must follow the physician\u0027s recommendation to remain in the practice is inappropriate because a competent patient may refuse recommendations; coercion undermines autonomy."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "End the physician-patient relationship because the patient rejects the recommendation is inappropriate because disagreement over a nonemergent treatment decision does not justify abandoning a patient who needs ongoing care."
            },
            {
              "id": "B",
              "text": "Option A: State that the patient must follow the physician\u0027s recommendation to remain in the practice is inappropriate because a competent patient may refuse recommendations; coercion undermines autonomy."
            },
            {
              "id": "C",
              "text": "Option D: Tell the patient that use of the capsule is at the patient\u0027s own risk and that the physician has no responsibility is inappropriate because risk disclosure does not eliminate the physician\u0027s duty to provide appropriate ongoing care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "End the physician-patient relationship because the patient rejects the recommendation is inappropriate because disagreement over a nonemergent treatment decision does not justify abandoning a patient who needs ongoing care."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tell the patient that use of the capsule is at the patient\u0027s own risk and that the physician has no responsibility is inappropriate because risk disclosure does not eliminate the physician\u0027s duty to provide appropriate ongoing care."
            },
            {
              "id": "B",
              "text": "Option A: State that the patient must follow the physician\u0027s recommendation to remain in the practice is inappropriate because a competent patient may refuse recommendations; coercion undermines autonomy."
            },
            {
              "id": "C",
              "text": "Option B: End the physician-patient relationship because the patient rejects the recommendation is inappropriate because disagreement over a nonemergent treatment decision does not justify abandoning a patient who needs ongoing care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tell the patient that use of the capsule is at the patient\u0027s own risk and that the physician has no responsibility is inappropriate because risk disclosure does not eliminate the physician\u0027s duty to provide appropriate ongoing care."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Require the patient to sign a waiver releasing the physician from responsibility before providing care is inappropriate because a liability waiver is inappropriate and does not replace informed consent or clinical follow-up."
            },
            {
              "id": "B",
              "text": "Option A: State that the patient must follow the physician\u0027s recommendation to remain in the practice is inappropriate because a competent patient may refuse recommendations; coercion undermines autonomy."
            },
            {
              "id": "C",
              "text": "Option B: End the physician-patient relationship because the patient rejects the recommendation is inappropriate because disagreement over a nonemergent treatment decision does not justify abandoning a patient who needs ongoing care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Require the patient to sign a waiver releasing the physician from responsibility before providing care is inappropriate because a liability waiver is inappropriate and does not replace informed consent or clinical follow-up."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discontinue lisinopril while the patient uses the herbal capsule to prevent a possible interaction is inappropriate because the patient\u0027s hypertension is controlled on lisinopril, and only a possible interaction has been discussed. Automatically withdrawing effective treatment disregards the patient\u0027s informed plan to continue both and is not a substitute for monitoring."
            },
            {
              "id": "B",
              "text": "Option A: State that the patient must follow the physician\u0027s recommendation to remain in the practice is inappropriate because a competent patient may refuse recommendations; coercion undermines autonomy."
            },
            {
              "id": "C",
              "text": "Option B: End the physician-patient relationship because the patient rejects the recommendation is inappropriate because disagreement over a nonemergent treatment decision does not justify abandoning a patient who needs ongoing care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discontinue lisinopril while the patient uses the herbal capsule to prevent a possible interaction is inappropriate because the patient\u0027s hypertension is controlled on lisinopril, and only a possible interaction has been discussed. Automatically withdrawing effective treatment disregards the patient\u0027s informed plan to continue both and is not a substitute for monitoring."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe or formally endorse the herbal capsule so that its use remains under medical supervision is inappropriate because respecting autonomy does not require the physician to prescribe or endorse an intervention with uncertain efficacy and interactions. The physician can decline to recommend it while continuing care and harm-reduction monitoring."
            },
            {
              "id": "B",
              "text": "Option A: State that the patient must follow the physician\u0027s recommendation to remain in the practice is inappropriate because a competent patient may refuse recommendations; coercion undermines autonomy."
            },
            {
              "id": "C",
              "text": "Option B: End the physician-patient relationship because the patient rejects the recommendation is inappropriate because disagreement over a nonemergent treatment decision does not justify abandoning a patient who needs ongoing care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe or formally endorse the herbal capsule so that its use remains under medical supervision is inappropriate because respecting autonomy does not require the physician to prescribe or endorse an intervention with uncertain efficacy and interactions. The physician can decline to recommend it while continuing care and harm-reduction monitoring."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Document the discussion but defer laboratory and blood-pressure monitoring unless symptoms develop is inappropriate because the patient has agreed to blood-pressure checks and laboratory monitoring, which can detect foreseeable harms before symptoms occur. Documentation alone does not replace appropriate follow-up."
            },
            {
              "id": "B",
              "text": "Option A: State that the patient must follow the physician\u0027s recommendation to remain in the practice is inappropriate because a competent patient may refuse recommendations; coercion undermines autonomy."
            },
            {
              "id": "C",
              "text": "Option B: End the physician-patient relationship because the patient rejects the recommendation is inappropriate because disagreement over a nonemergent treatment decision does not justify abandoning a patient who needs ongoing care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Document the discussion but defer laboratory and blood-pressure monitoring unless symptoms develop is inappropriate because the patient has agreed to blood-pressure checks and laboratory monitoring, which can detect foreseeable harms before symptoms occur. Documentation alone does not replace appropriate follow-up."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i030-autonomy-treatment-refusal",
      "expectedHashes": {
        "ranaze_step3_uat": "595096a222984fc461f6dcbf6e363412256ec5faf4654c6a0dceb42b8de3791c",
        "ranaze_step3_prd": "595096a222984fc461f6dcbf6e363412256ec5faf4654c6a0dceb42b8de3791c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
            },
            {
              "id": "B",
              "text": "Option C: Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
            },
            {
              "id": "C",
              "text": "Option D: Nonmaleficence supports avoiding harm but does not permit overriding an informed refusal by a capable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
            },
            {
              "id": "B",
              "text": "Option B: Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
            },
            {
              "id": "C",
              "text": "Option D: Nonmaleficence supports avoiding harm but does not permit overriding an informed refusal by a capable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nonmaleficence supports avoiding harm but does not permit overriding an informed refusal by a capable patient."
            },
            {
              "id": "B",
              "text": "Option B: Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
            },
            {
              "id": "C",
              "text": "Option C: Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nonmaleficence supports avoiding harm but does not permit overriding an informed refusal by a capable patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Standard of care informs the recommendation for biopsy but is not the primary ethical principle governing refusal."
            },
            {
              "id": "B",
              "text": "Option B: Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
            },
            {
              "id": "C",
              "text": "Option C: Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Standard of care informs the recommendation for biopsy but is not the primary ethical principle governing refusal."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Paternalism would prioritize the clinician\u2019s judgment and could override the patient\u2019s preference for her perceived welfare. That is not justified when an adult demonstrates decision-making capacity and makes an informed refusal."
            },
            {
              "id": "B",
              "text": "Option B: Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
            },
            {
              "id": "C",
              "text": "Option C: Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Paternalism would prioritize the clinician\u2019s judgment and could override the patient\u2019s preference for her perceived welfare. That is not justified when an adult demonstrates decision-making capacity and makes an informed refusal."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Substituted judgment is used by a surrogate to approximate the wishes of a patient who lacks capacity. This patient is alert, understands the consequences, and is expressing her own choice."
            },
            {
              "id": "B",
              "text": "Option B: Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
            },
            {
              "id": "C",
              "text": "Option C: Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Substituted judgment is used by a surrogate to approximate the wishes of a patient who lacks capacity. This patient is alert, understands the consequences, and is expressing her own choice."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Veracity requires truthful communication and supports the clinician\u2019s explanation that malignancy is possible. Once adequately informed, however, the patient\u2019s decision is governed primarily by autonomy."
            },
            {
              "id": "B",
              "text": "Option B: Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
            },
            {
              "id": "C",
              "text": "Option C: Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Veracity requires truthful communication and supports the clinician\u2019s explanation that malignancy is possible. Once adequately informed, however, the patient\u2019s decision is governed primarily by autonomy."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fidelity concerns faithfulness to professional commitments and the therapeutic relationship. It supports continued care but is not the primary principle determining whether this capable patient may decline biopsy."
            },
            {
              "id": "B",
              "text": "Option B: Beneficence supports recommending biopsy but does not override a capable patient\u0027s informed refusal."
            },
            {
              "id": "C",
              "text": "Option C: Justice concerns fair distribution of health resources and nondiscrimination, not this individual refusal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fidelity concerns faithfulness to professional commitments and the therapeutic relationship. It supports continued care but is not the primary principle determining whether this capable patient may decline biopsy."
        }
      }
    },
    {
      "externalId": "nbme5-s3-i032-pheochromocytoma-testing",
      "expectedHashes": {
        "ranaze_step3_uat": "a37203dd6597839e767b8c8a0fb7aa0dbdc23faf014d9d975cf3cea86490ec72",
        "ranaze_step3_prd": "a37203dd6597839e767b8c8a0fb7aa0dbdc23faf014d9d975cf3cea86490ec72"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "B",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            },
            {
              "id": "C",
              "text": "Option D: Serum cortisol measurement is inappropriate because cortisol testing evaluates hypercortisolism, which typically causes persistent rather than episodic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option D: Serum cortisol measurement is inappropriate because cortisol testing evaluates hypercortisolism, which typically causes persistent rather than episodic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum cortisol measurement is inappropriate because cortisol testing evaluates hypercortisolism, which typically causes persistent rather than episodic symptoms."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum cortisol measurement is inappropriate because cortisol testing evaluates hypercortisolism, which typically causes persistent rather than episodic symptoms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thyroid ultrasound does not evaluate the catecholamine excess suggested by this presentation."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thyroid ultrasound does not evaluate the catecholamine excess suggested by this presentation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "24-hour urinary vanillylmandelic acid measurement is inappropriate because urinary vanillylmandelic acid is a catecholamine metabolite but is less sensitive than plasma free or urinary fractionated metanephrines. It is not the preferred initial biochemical study for this classic presentation."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "24-hour urinary vanillylmandelic acid measurement is inappropriate because urinary vanillylmandelic acid is a catecholamine metabolite but is less sensitive than plasma free or urinary fractionated metanephrines. It is not the preferred initial biochemical study for this classic presentation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plasma catecholamine measurement during a symptomatic episode is inappropriate because catecholamine secretion may be episodic, so trying to obtain plasma catecholamines during a spell is less reliable than measuring continuously produced metanephrines. Testing need not wait for another episode."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plasma catecholamine measurement during a symptomatic episode is inappropriate because catecholamine secretion may be episodic, so trying to obtain plasma catecholamines during a spell is less reliable than measuring continuously produced metanephrines. Testing need not wait for another episode."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Iodine-123 metaiodobenzylguanidine scintigraphy is inappropriate because metaiodobenzylguanidine scintigraphy is a localization or staging study used selectively after biochemical evidence of pheochromocytoma or paraganglioma, not the initial diagnostic study."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Iodine-123 metaiodobenzylguanidine scintigraphy is inappropriate because metaiodobenzylguanidine scintigraphy is a localization or staging study used selectively after biochemical evidence of pheochromocytoma or paraganglioma, not the initial diagnostic study."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ultrasonography of the kidneys is inappropriate because renal ultrasonography can evaluate renal parenchymal disease or anatomy but does not test for catecholamine excess and poorly accounts for discrete headache, diaphoresis, tremor, and palpitation spells."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ultrasonography of the kidneys is inappropriate because renal ultrasonography can evaluate renal parenchymal disease or anatomy but does not test for catecholamine excess and poorly accounts for discrete headache, diaphoresis, tremor, and palpitation spells."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum thyroid-stimulating hormone measurement is inappropriate because hyperthyroidism can cause weight loss, tremor, sweating, and tachycardia, but the marked hypertension and recurrent discrete adrenergic attacks make biochemical testing for pheochromocytoma the priority."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum thyroid-stimulating hormone measurement is inappropriate because hyperthyroidism can cause weight loss, tremor, sweating, and tachycardia, but the marked hypertension and recurrent discrete adrenergic attacks make biochemical testing for pheochromocytoma the priority."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urine toxicology screening for sympathomimetics is inappropriate because sympathomimetic exposure can mimic catecholamine excess, but the stem supplies no exposure history and describes recurrent stereotyped attacks over a month. A toxicology screen is not the preferred initial test for the strongly suspected endocrine syndrome."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urine toxicology screening for sympathomimetics is inappropriate because sympathomimetic exposure can mimic catecholamine excess, but the stem supplies no exposure history and describes recurrent stereotyped attacks over a month. A toxicology screen is not the preferred initial test for the strongly suspected endocrine syndrome."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Genetic testing for a hereditary pheochromocytoma syndrome is inappropriate because her young age raises the eventual importance of germline evaluation, but genetic testing neither demonstrates current catecholamine excess nor replaces initial biochemical confirmation."
            },
            {
              "id": "B",
              "text": "Option B: CT scan of the adrenal glands is inappropriate because adrenal imaging is performed after biochemical evidence supports catecholamine-secreting tumor."
            },
            {
              "id": "C",
              "text": "Option C: MR angiography of the renal arteries is inappropriate because renal artery imaging is appropriate when renovascular hypertension is suspected, but it does not explain the episodic adrenergic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Genetic testing for a hereditary pheochromocytoma syndrome is inappropriate because her young age raises the eventual importance of germline evaluation, but genetic testing neither demonstrates current catecholamine excess nor replaces initial biochemical confirmation."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i001-preconception-folic-acid",
      "expectedHashes": {
        "ranaze_step3_uat": "c1fb9dd617218a8fa530feca575d22a40e57481f5df1ded0904d520ab2b72240",
        "ranaze_step3_prd": "c1fb9dd617218a8fa530feca575d22a40e57481f5df1ded0904d520ab2b72240"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer depot medroxyprogesterone acetate is inappropriate because depot medroxyprogesterone may delay return to fertility and conflicts with planned conception in the near future."
            },
            {
              "id": "B",
              "text": "Option C: Obtain screening mammography before conception is inappropriate because routine mammography is not indicated at age 27 based only on one aunt with breast cancer at an older age."
            },
            {
              "id": "C",
              "text": "Option D: Recommend abstinence until pregnancy is desired is inappropriate because abstinence is not medically indicated for this mutually monogamous couple planning pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer depot medroxyprogesterone acetate is inappropriate because depot medroxyprogesterone may delay return to fertility and conflicts with planned conception in the near future."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain screening mammography before conception is inappropriate because routine mammography is not indicated at age 27 based only on one aunt with breast cancer at an older age."
            },
            {
              "id": "B",
              "text": "Option B: Administer depot medroxyprogesterone acetate is inappropriate because depot medroxyprogesterone may delay return to fertility and conflicts with planned conception in the near future."
            },
            {
              "id": "C",
              "text": "Option D: Recommend abstinence until pregnancy is desired is inappropriate because abstinence is not medically indicated for this mutually monogamous couple planning pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain screening mammography before conception is inappropriate because routine mammography is not indicated at age 27 based only on one aunt with breast cancer at an older age."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend abstinence until pregnancy is desired is inappropriate because abstinence is not medically indicated for this mutually monogamous couple planning pregnancy."
            },
            {
              "id": "B",
              "text": "Option B: Administer depot medroxyprogesterone acetate is inappropriate because depot medroxyprogesterone may delay return to fertility and conflicts with planned conception in the near future."
            },
            {
              "id": "C",
              "text": "Option C: Obtain screening mammography before conception is inappropriate because routine mammography is not indicated at age 27 based only on one aunt with breast cancer at an older age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend abstinence until pregnancy is desired is inappropriate because abstinence is not medically indicated for this mutually monogamous couple planning pregnancy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform routine screening for sexually transmitted infections is inappropriate because risk-based STI screening is appropriate when risk factors are present, but this low-risk patient most clearly needs preconception folic acid."
            },
            {
              "id": "B",
              "text": "Option B: Administer depot medroxyprogesterone acetate is inappropriate because depot medroxyprogesterone may delay return to fertility and conflicts with planned conception in the near future."
            },
            {
              "id": "C",
              "text": "Option C: Obtain screening mammography before conception is inappropriate because routine mammography is not indicated at age 27 based only on one aunt with breast cancer at an older age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform routine screening for sexually transmitted infections is inappropriate because risk-based STI screening is appropriate when risk factors are present, but this low-risk patient most clearly needs preconception folic acid."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin folic acid supplementation after a positive pregnancy test is inappropriate because neural tube closure occurs very early, often before pregnancy is recognized. Folic acid should begin at least 1 month before conception rather than waiting for a positive pregnancy test."
            },
            {
              "id": "B",
              "text": "Option B: Administer depot medroxyprogesterone acetate is inappropriate because depot medroxyprogesterone may delay return to fertility and conflicts with planned conception in the near future."
            },
            {
              "id": "C",
              "text": "Option C: Obtain screening mammography before conception is inappropriate because routine mammography is not indicated at age 27 based only on one aunt with breast cancer at an older age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin folic acid supplementation after a positive pregnancy test is inappropriate because neural tube closure occurs very early, often before pregnancy is recognized. Folic acid should begin at least 1 month before conception rather than waiting for a positive pregnancy test."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain serum anti-M\u00FCllerian hormone measurement is inappropriate because anti-M\u00FCllerian hormone can estimate ovarian response in infertility treatment but is not a screening test for natural fertility in an asymptomatic 27-year-old who has not yet attempted conception."
            },
            {
              "id": "B",
              "text": "Option B: Administer depot medroxyprogesterone acetate is inappropriate because depot medroxyprogesterone may delay return to fertility and conflicts with planned conception in the near future."
            },
            {
              "id": "C",
              "text": "Option C: Obtain screening mammography before conception is inappropriate because routine mammography is not indicated at age 27 based only on one aunt with breast cancer at an older age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain serum anti-M\u00FCllerian hormone measurement is inappropriate because anti-M\u00FCllerian hormone can estimate ovarian response in infertility treatment but is not a screening test for natural fertility in an asymptomatic 27-year-old who has not yet attempted conception."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer for BRCA1 and BRCA2 genetic testing is inappropriate because one second-degree relative with breast cancer at age 71 does not by itself suggest a hereditary breast-ovarian cancer syndrome requiring BRCA testing. This does not replace universal folic acid supplementation."
            },
            {
              "id": "B",
              "text": "Option B: Administer depot medroxyprogesterone acetate is inappropriate because depot medroxyprogesterone may delay return to fertility and conflicts with planned conception in the near future."
            },
            {
              "id": "C",
              "text": "Option C: Obtain screening mammography before conception is inappropriate because routine mammography is not indicated at age 27 based only on one aunt with breast cancer at an older age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer for BRCA1 and BRCA2 genetic testing is inappropriate because one second-degree relative with breast cancer at age 71 does not by itself suggest a hereditary breast-ovarian cancer syndrome requiring BRCA testing. This does not replace universal folic acid supplementation."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i002-septic-arthritis-treatment",
      "expectedHashes": {
        "ranaze_step3_uat": "e7e95961438019a9fcd122ae72fba240f8030aea46d336b0ffdcd6b7f0a552a2",
        "ranaze_step3_prd": "e7e95961438019a9fcd122ae72fba240f8030aea46d336b0ffdcd6b7f0a552a2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer treatment until synovial fluid cultures are finalized is inappropriate because waiting for cultures can delay treatment of septic arthritis and increase the risk of irreversible joint destruction."
            },
            {
              "id": "B",
              "text": "Option C: Treat with an NSAID and arrange close outpatient follow-up is inappropriate because nSAID-only outpatient management is inappropriate when synovial findings strongly suggest bacterial joint infection."
            },
            {
              "id": "C",
              "text": "Option D: Obtain MRI of the ankle before treatment is inappropriate because mRI is not required before treating suspected septic arthritis after diagnostic arthrocentesis has been performed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer treatment until synovial fluid cultures are finalized is inappropriate because waiting for cultures can delay treatment of septic arthritis and increase the risk of irreversible joint destruction."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with an NSAID and arrange close outpatient follow-up is inappropriate because nSAID-only outpatient management is inappropriate when synovial findings strongly suggest bacterial joint infection."
            },
            {
              "id": "B",
              "text": "Option B: Defer treatment until synovial fluid cultures are finalized is inappropriate because waiting for cultures can delay treatment of septic arthritis and increase the risk of irreversible joint destruction."
            },
            {
              "id": "C",
              "text": "Option D: Obtain MRI of the ankle before treatment is inappropriate because mRI is not required before treating suspected septic arthritis after diagnostic arthrocentesis has been performed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with an NSAID and arrange close outpatient follow-up is inappropriate because nSAID-only outpatient management is inappropriate when synovial findings strongly suggest bacterial joint infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain MRI of the ankle before treatment is inappropriate because mRI is not required before treating suspected septic arthritis after diagnostic arthrocentesis has been performed."
            },
            {
              "id": "B",
              "text": "Option B: Defer treatment until synovial fluid cultures are finalized is inappropriate because waiting for cultures can delay treatment of septic arthritis and increase the risk of irreversible joint destruction."
            },
            {
              "id": "C",
              "text": "Option C: Treat with an NSAID and arrange close outpatient follow-up is inappropriate because nSAID-only outpatient management is inappropriate when synovial findings strongly suggest bacterial joint infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain MRI of the ankle before treatment is inappropriate because mRI is not required before treating suspected septic arthritis after diagnostic arthrocentesis has been performed."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start colchicine therapy is inappropriate because colchicine is used for crystal arthritis, but no crystals were identified and the synovial leukocyte count is markedly elevated."
            },
            {
              "id": "B",
              "text": "Option B: Defer treatment until synovial fluid cultures are finalized is inappropriate because waiting for cultures can delay treatment of septic arthritis and increase the risk of irreversible joint destruction."
            },
            {
              "id": "C",
              "text": "Option C: Treat with an NSAID and arrange close outpatient follow-up is inappropriate because nSAID-only outpatient management is inappropriate when synovial findings strongly suggest bacterial joint infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start colchicine therapy is inappropriate because colchicine is used for crystal arthritis, but no crystals were identified and the synovial leukocyte count is markedly elevated."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin oral amoxicillin-clavulanate and discharge with follow-up is inappropriate because initial outpatient oral therapy is inadequate for this febrile patient with rapidly progressive monoarthritis and markedly purulent, neutrophil-predominant synovial fluid. Suspected native-joint septic arthritis requires prompt empiric treatment after diagnostic fluid has been collected; oral step-down is considered only after initial treatment and clinical improvement."
            },
            {
              "id": "B",
              "text": "Option B: Defer treatment until synovial fluid cultures are finalized is inappropriate because waiting for cultures can delay treatment of septic arthritis and increase the risk of irreversible joint destruction."
            },
            {
              "id": "C",
              "text": "Option C: Treat with an NSAID and arrange close outpatient follow-up is inappropriate because nSAID-only outpatient management is inappropriate when synovial findings strongly suggest bacterial joint infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin oral amoxicillin-clavulanate and discharge with follow-up is inappropriate because initial outpatient oral therapy is inadequate for this febrile patient with rapidly progressive monoarthritis and markedly purulent, neutrophil-predominant synovial fluid. Suspected native-joint septic arthritis requires prompt empiric treatment after diagnostic fluid has been collected; oral step-down is considered only after initial treatment and clinical improvement."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inject an intra-articular glucocorticoid is inappropriate because an intra-articular glucocorticoid could suppress local host defenses in a joint with a strongly suspected bacterial infection. The turbid fluid and marked neutrophilic leukocytosis require antimicrobial treatment and joint-source control, not steroid injection."
            },
            {
              "id": "B",
              "text": "Option B: Defer treatment until synovial fluid cultures are finalized is inappropriate because waiting for cultures can delay treatment of septic arthritis and increase the risk of irreversible joint destruction."
            },
            {
              "id": "C",
              "text": "Option C: Treat with an NSAID and arrange close outpatient follow-up is inappropriate because nSAID-only outpatient management is inappropriate when synovial findings strongly suggest bacterial joint infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inject an intra-articular glucocorticoid is inappropriate because an intra-articular glucocorticoid could suppress local host defenses in a joint with a strongly suspected bacterial infection. The turbid fluid and marked neutrophilic leukocytosis require antimicrobial treatment and joint-source control, not steroid injection."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform arthroscopic irrigation and debridement without starting antibiotics is inappropriate because joint drainage is an important component of septic-arthritis management, but it does not replace systemic antimicrobial therapy. Arthroscopic irrigation without prompt antibiotics leaves the invasive infection untreated."
            },
            {
              "id": "B",
              "text": "Option B: Defer treatment until synovial fluid cultures are finalized is inappropriate because waiting for cultures can delay treatment of septic arthritis and increase the risk of irreversible joint destruction."
            },
            {
              "id": "C",
              "text": "Option C: Treat with an NSAID and arrange close outpatient follow-up is inappropriate because nSAID-only outpatient management is inappropriate when synovial findings strongly suggest bacterial joint infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform arthroscopic irrigation and debridement without starting antibiotics is inappropriate because joint drainage is an important component of septic-arthritis management, but it does not replace systemic antimicrobial therapy. Arthroscopic irrigation without prompt antibiotics leaves the invasive infection untreated."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i003-acute-ischemic-stroke-thrombolysis",
      "expectedHashes": {
        "ranaze_step3_uat": "7d56d10801b2a74584144689ff853c8e0f9786a9b8d75c125dfc3c3a8db3e270",
        "ranaze_step3_prd": "7d56d10801b2a74584144689ff853c8e0f9786a9b8d75c125dfc3c3a8db3e270"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "B",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            },
            {
              "id": "C",
              "text": "Option D: Perform carotid endarterectomy immediately is inappropriate because carotid endarterectomy is not an immediate treatment for an acute disabling stroke."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option D: Perform carotid endarterectomy immediately is inappropriate because carotid endarterectomy is not an immediate treatment for an acute disabling stroke."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform carotid endarterectomy immediately is inappropriate because carotid endarterectomy is not an immediate treatment for an acute disabling stroke."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform carotid endarterectomy immediately is inappropriate because carotid endarterectomy is not an immediate treatment for an acute disabling stroke."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intra-arterial streptokinase is inappropriate because streptokinase is not used for acute ischemic stroke because of poor safety and efficacy compared with recommended thrombolytic therapy."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intra-arterial streptokinase is inappropriate because streptokinase is not used for acute ischemic stroke because of poor safety and efficacy compared with recommended thrombolytic therapy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower the systolic blood pressure to less than 140 mm Hg with intravenous labetalol before reperfusion therapy is inappropriate because her blood pressure of 164/88 mm Hg is already below the pretreatment threshold used for intravenous thrombolysis. Intensive reduction to below 140 mm Hg is unnecessary and would delay reperfusion; current guidance also cautions against intensive early blood-pressure lowering."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower the systolic blood pressure to less than 140 mm Hg with intravenous labetalol before reperfusion therapy is inappropriate because her blood pressure of 164/88 mm Hg is already below the pretreatment threshold used for intravenous thrombolysis. Intensive reduction to below 140 mm Hg is unnecessary and would delay reperfusion; current guidance also cautions against intensive early blood-pressure lowering."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain CT angiography and perfusion imaging before initiating any reperfusion treatment is inappropriate because vascular imaging is appropriate when evaluating possible large-vessel occlusion and thrombectomy, but it must not delay intravenous thrombolysis in an otherwise eligible patient. She is within 75 minutes of onset and does not require advanced-imaging selection for thrombolysis."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain CT angiography and perfusion imaging before initiating any reperfusion treatment is inappropriate because vascular imaging is appropriate when evaluating possible large-vessel occlusion and thrombectomy, but it must not delay intravenous thrombolysis in an otherwise eligible patient. She is within 75 minutes of onset and does not require advanced-imaging selection for thrombolysis."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain diffusion-weighted brain MRI before initiating treatment is inappropriate because mRI is unnecessary before thrombolysis in this early-window patient because noncontrast CT has already excluded intracranial hemorrhage. Waiting for MRI would delay time-sensitive treatment."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain diffusion-weighted brain MRI before initiating treatment is inappropriate because mRI is unnecessary before thrombolysis in this early-window patient because noncontrast CT has already excluded intracranial hemorrhage. Waiting for MRI would delay time-sensitive treatment."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer aspirin and clopidogrel instead of thrombolysis is inappropriate because dual antiplatelet therapy is favored for selected minor, nondisabling strokes, not for this disabling syndrome with expressive aphasia and dense arm weakness. Eligible patients with disabling deficits should receive prompt intravenous thrombolysis."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer aspirin and clopidogrel instead of thrombolysis is inappropriate because dual antiplatelet therapy is favored for selected minor, nondisabling strokes, not for this disabling syndrome with expressive aphasia and dense arm weakness. Eligible patients with disabling deficits should receive prompt intravenous thrombolysis."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold thrombolysis because the noncontrast CT shows no infarction is inappropriate because a normal-appearing noncontrast CT early after symptom onset is expected in many ischemic strokes. Its acute purpose is principally to exclude hemorrhage; absence of a visible infarct does not contraindicate thrombolysis."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold thrombolysis because the noncontrast CT shows no infarction is inappropriate because a normal-appearing noncontrast CT early after symptom onset is expected in many ischemic strokes. Its acute purpose is principally to exclude hemorrhage; absence of a visible infarct does not contraindicate thrombolysis."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain carotid duplex ultrasonography before deciding on acute treatment is inappropriate because carotid duplex may help determine stroke mechanism and later secondary prevention, but it does not select an otherwise eligible early-window patient for intravenous thrombolysis and should not delay treatment."
            },
            {
              "id": "B",
              "text": "Option B: Begin intravenous unfractionated heparin is inappropriate because acute heparin anticoagulation does not provide the benefit of thrombolysis for this presentation and increases bleeding risk."
            },
            {
              "id": "C",
              "text": "Option C: Give aspirin alone and observe is inappropriate because aspirin is used when thrombolysis is not given, but it is not the preferred initial therapy for this eligible patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain carotid duplex ultrasonography before deciding on acute treatment is inappropriate because carotid duplex may help determine stroke mechanism and later secondary prevention, but it does not select an otherwise eligible early-window patient for intravenous thrombolysis and should not delay treatment."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i004-cll-elective-surgery",
      "expectedHashes": {
        "ranaze_step3_uat": "bd34a85f19480085b734d125be7a6a225a139cb322fcaec32b8d510833cf9bd1",
        "ranaze_step3_prd": "bd34a85f19480085b734d125be7a6a225a139cb322fcaec32b8d510833cf9bd1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "B",
              "text": "Option C: It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            },
            {
              "id": "C",
              "text": "Option D: It should be delayed until plasmapheresis is performed is inappropriate because plasmapheresis is not used to manage uncomplicated chronic lymphocytic leukemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            },
            {
              "id": "B",
              "text": "Option B: It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "C",
              "text": "Option D: It should be delayed until plasmapheresis is performed is inappropriate because plasmapheresis is not used to manage uncomplicated chronic lymphocytic leukemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It should be delayed until plasmapheresis is performed is inappropriate because plasmapheresis is not used to manage uncomplicated chronic lymphocytic leukemia."
            },
            {
              "id": "B",
              "text": "Option B: It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "C",
              "text": "Option C: It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It should be delayed until plasmapheresis is performed is inappropriate because plasmapheresis is not used to manage uncomplicated chronic lymphocytic leukemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It should be delayed until he receives a packed red blood cell transfusion is inappropriate because his hemoglobin concentration does not meet a typical transfusion threshold and he has no symptomatic anemia."
            },
            {
              "id": "B",
              "text": "Option B: It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "C",
              "text": "Option C: It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It should be delayed until he receives a packed red blood cell transfusion is inappropriate because his hemoglobin concentration does not meet a typical transfusion threshold and he has no symptomatic anemia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay the operation until he completes a course of acalabrutinib is inappropriate because acalabrutinib is a CLL-directed BTK inhibitor, but asymptomatic or minimally affected CLL is managed with observation. His mild cytopenias, small mobile nodes, excellent functional status, and absence of constitutional symptoms do not justify treatment before hernia repair."
            },
            {
              "id": "B",
              "text": "Option B: It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "C",
              "text": "Option C: It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay the operation until he completes a course of acalabrutinib is inappropriate because acalabrutinib is a CLL-directed BTK inhibitor, but asymptomatic or minimally affected CLL is managed with observation. His mild cytopenias, small mobile nodes, excellent functional status, and absence of constitutional symptoms do not justify treatment before hernia repair."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay the operation until he receives a platelet transfusion is inappropriate because a platelet count of 142,000/mm3 is adequate for elective hernia repair, and he reports no easy bruising. Prophylactic platelet transfusion is unnecessary and exposes him to transfusion risks."
            },
            {
              "id": "B",
              "text": "Option B: It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "C",
              "text": "Option C: It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay the operation until he receives a platelet transfusion is inappropriate because a platelet count of 142,000/mm3 is adequate for elective hernia repair, and he reports no easy bruising. Prophylactic platelet transfusion is unnecessary and exposes him to transfusion risks."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay the operation until leukapheresis lowers the leukocyte count is inappropriate because cLL lymphocytes commonly produce a high leukocyte count without the leukostasis syndrome seen in acute leukemias. A count of 46,000/mm3 in an asymptomatic patient is not an indication for leukapheresis or surgical delay."
            },
            {
              "id": "B",
              "text": "Option B: It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "C",
              "text": "Option C: It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay the operation until leukapheresis lowers the leukocyte count is inappropriate because cLL lymphocytes commonly produce a high leukocyte count without the leukostasis syndrome seen in acute leukemias. A count of 46,000/mm3 in an asymptomatic patient is not an indication for leukapheresis or surgical delay."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay the operation until he receives intravenous immune globulin is inappropriate because intravenous immune globulin may be considered in selected CLL patients with hypogammaglobulinemia and recurrent serious infections. This patient specifically reports no recurrent infections, so prophylactic IVIG is unwarranted."
            },
            {
              "id": "B",
              "text": "Option B: It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "C",
              "text": "Option C: It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay the operation until he receives intravenous immune globulin is inappropriate because intravenous immune globulin may be considered in selected CLL patients with hypogammaglobulinemia and recurrent serious infections. This patient specifically reports no recurrent infections, so prophylactic IVIG is unwarranted."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay the operation until CT staging of the chest, abdomen, and pelvis is completed is inappropriate because routine baseline or surveillance CT does not improve survival and is unnecessary for staging or prognostication in asymptomatic early-stage CLL. It should not delay the operation."
            },
            {
              "id": "B",
              "text": "Option B: It should be delayed until he completes intravenous antibiotics is inappropriate because there is no evidence of an active infection requiring antibiotics."
            },
            {
              "id": "C",
              "text": "Option C: It should be delayed until he receives radiation therapy is inappropriate because radiation therapy is not indicated for asymptomatic diffuse lymphocytosis and would not be required before surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay the operation until CT staging of the chest, abdomen, and pelvis is completed is inappropriate because routine baseline or surveillance CT does not improve survival and is unnecessary for staging or prognostication in asymptomatic early-stage CLL. It should not delay the operation."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i005-smoking-cessation-copd",
      "expectedHashes": {
        "ranaze_step3_uat": "f961e6392ad7dfe28e8e1e19d46b6ce0b3cfb033784508086e870b727eacf24e",
        "ranaze_step3_prd": "f961e6392ad7dfe28e8e1e19d46b6ce0b3cfb033784508086e870b727eacf24e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reducing to several cigarettes daily will restore normal lung function is inappropriate because reducing smoking is preferable to continued heavy smoking but does not restore normal lung function."
            },
            {
              "id": "B",
              "text": "Option C: Quitting now will return your spirometry to normal is inappropriate because established airflow obstruction generally does not normalize after smoking cessation."
            },
            {
              "id": "C",
              "text": "Option D: Stopping smoking cannot improve your respiratory prognosis because airway damage is established is inappropriate because smoking cessation remains beneficial at any stage because it slows further loss of lung function."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reducing to several cigarettes daily will restore normal lung function is inappropriate because reducing smoking is preferable to continued heavy smoking but does not restore normal lung function."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Quitting now will return your spirometry to normal is inappropriate because established airflow obstruction generally does not normalize after smoking cessation."
            },
            {
              "id": "B",
              "text": "Option B: Reducing to several cigarettes daily will restore normal lung function is inappropriate because reducing smoking is preferable to continued heavy smoking but does not restore normal lung function."
            },
            {
              "id": "C",
              "text": "Option D: Stopping smoking cannot improve your respiratory prognosis because airway damage is established is inappropriate because smoking cessation remains beneficial at any stage because it slows further loss of lung function."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Quitting now will return your spirometry to normal is inappropriate because established airflow obstruction generally does not normalize after smoking cessation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stopping smoking cannot improve your respiratory prognosis because airway damage is established is inappropriate because smoking cessation remains beneficial at any stage because it slows further loss of lung function."
            },
            {
              "id": "B",
              "text": "Option B: Reducing to several cigarettes daily will restore normal lung function is inappropriate because reducing smoking is preferable to continued heavy smoking but does not restore normal lung function."
            },
            {
              "id": "C",
              "text": "Option C: Quitting now will return your spirometry to normal is inappropriate because established airflow obstruction generally does not normalize after smoking cessation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stopping smoking cannot improve your respiratory prognosis because airway damage is established is inappropriate because smoking cessation remains beneficial at any stage because it slows further loss of lung function."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continued smoking at a reduced amount has the same benefit as complete cessation is inappropriate because complete cessation provides greater benefit than continuing to smoke, even at a reduced amount."
            },
            {
              "id": "B",
              "text": "Option B: Reducing to several cigarettes daily will restore normal lung function is inappropriate because reducing smoking is preferable to continued heavy smoking but does not restore normal lung function."
            },
            {
              "id": "C",
              "text": "Option C: Quitting now will return your spirometry to normal is inappropriate because established airflow obstruction generally does not normalize after smoking cessation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continued smoking at a reduced amount has the same benefit as complete cessation is inappropriate because complete cessation provides greater benefit than continuing to smoke, even at a reduced amount."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maintenance inhaler therapy can substitute for complete smoking cessation in slowing lung-function decline is inappropriate because maintenance inhalers can reduce symptoms and exacerbations, but they do not replace smoking cessation as the key intervention for reducing ongoing tobacco-related loss of lung function."
            },
            {
              "id": "B",
              "text": "Option B: Reducing to several cigarettes daily will restore normal lung function is inappropriate because reducing smoking is preferable to continued heavy smoking but does not restore normal lung function."
            },
            {
              "id": "C",
              "text": "Option C: Quitting now will return your spirometry to normal is inappropriate because established airflow obstruction generally does not normalize after smoking cessation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maintenance inhaler therapy can substitute for complete smoking cessation in slowing lung-function decline is inappropriate because maintenance inhalers can reduce symptoms and exacerbations, but they do not replace smoking cessation as the key intervention for reducing ongoing tobacco-related loss of lung function."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i007-resectable-lung-cancer",
      "expectedHashes": {
        "ranaze_step3_uat": "b6b0921ae0338411af8aa420f76b232edc347b2f7bb7738111e0b1aae4985ffc",
        "ranaze_step3_prd": "b6b0921ae0338411af8aa420f76b232edc347b2f7bb7738111e0b1aae4985ffc"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "B",
              "text": "Option B: Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            },
            {
              "id": "C",
              "text": "Option D: Systemic chemotherapy alone is inappropriate because chemotherapy alone is not curative for an operable localized tumor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            },
            {
              "id": "B",
              "text": "Option A: Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "C",
              "text": "Option D: Systemic chemotherapy alone is inappropriate because chemotherapy alone is not curative for an operable localized tumor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Systemic chemotherapy alone is inappropriate because chemotherapy alone is not curative for an operable localized tumor."
            },
            {
              "id": "B",
              "text": "Option A: Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "C",
              "text": "Option B: Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Systemic chemotherapy alone is inappropriate because chemotherapy alone is not curative for an operable localized tumor."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Referral for hospice care is inappropriate because hospice is inappropriate for a localized cancer with curative treatment options."
            },
            {
              "id": "B",
              "text": "Option A: Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "C",
              "text": "Option B: Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Referral for hospice care is inappropriate because hospice is inappropriate for a localized cancer with curative treatment options."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stereotactic body radiation therapy instead of surgery is inappropriate because stereotactic body radiation therapy is a curative alternative mainly for patients who cannot undergo or decline surgery. This patient has localized disease and adequate functional reserve, so surgical resection with nodal evaluation is preferred."
            },
            {
              "id": "B",
              "text": "Option A: Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "C",
              "text": "Option B: Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stereotactic body radiation therapy instead of surgery is inappropriate because stereotactic body radiation therapy is a curative alternative mainly for patients who cannot undergo or decline surgery. This patient has localized disease and adequate functional reserve, so surgical resection with nodal evaluation is preferred."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wedge resection without lymph-node evaluation is inappropriate because a wedge resection without nodal evaluation is inadequate oncologic management for a fit patient with a 2.4-cm invasive NSCLC. Nodal assessment is required for pathologic staging, and lobectomy is the established surgical choice here."
            },
            {
              "id": "B",
              "text": "Option A: Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "C",
              "text": "Option B: Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wedge resection without lymph-node evaluation is inappropriate because a wedge resection without nodal evaluation is inadequate oncologic management for a fit patient with a 2.4-cm invasive NSCLC. Nodal assessment is required for pathologic staging, and lobectomy is the established surgical choice here."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Right pneumonectomy is inappropriate because pneumonectomy removes substantially more functional lung than necessary for a mass confined to the right upper lobe; lobectomy achieves anatomic resection while preserving the remaining lobes."
            },
            {
              "id": "B",
              "text": "Option A: Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "C",
              "text": "Option B: Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Right pneumonectomy is inappropriate because pneumonectomy removes substantially more functional lung than necessary for a mass confined to the right upper lobe; lobectomy achieves anatomic resection while preserving the remaining lobes."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neoadjuvant chemotherapy and immunotherapy before considering resection is inappropriate because routine neoadjuvant chemotherapy or immunotherapy is not indicated for this apparent 2.4-cm node-negative stage IA tumor; upfront surgery is appropriate."
            },
            {
              "id": "B",
              "text": "Option A: Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "C",
              "text": "Option B: Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neoadjuvant chemotherapy and immunotherapy before considering resection is inappropriate because routine neoadjuvant chemotherapy or immunotherapy is not indicated for this apparent 2.4-cm node-negative stage IA tumor; upfront surgery is appropriate."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Percutaneous radiofrequency ablation is inappropriate because percutaneous ablation is generally reserved for selected nonsurgical candidates. A fit patient with operable stage I NSCLC should undergo surgical resection and nodal evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Definitive concurrent chemoradiation is inappropriate because chemoradiation is generally used for unresectable locally advanced disease or when surgery is not feasible."
            },
            {
              "id": "C",
              "text": "Option B: Endobronchial laser ablation alone is inappropriate because laser therapy may palliate an obstructing endobronchial lesion but is not definitive therapy for localized operable lung cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Percutaneous radiofrequency ablation is inappropriate because percutaneous ablation is generally reserved for selected nonsurgical candidates. A fit patient with operable stage I NSCLC should undergo surgical resection and nodal evaluation."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i010-bacterial-paronychia-cellulitis",
      "expectedHashes": {
        "ranaze_step3_uat": "8ad2439686e51d17088d57efe94670f42461442fa7072e71c7393f9c325ad570",
        "ranaze_step3_prd": "8ad2439686e51d17088d57efe94670f42461442fa7072e71c7393f9c325ad570"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical terbinafine treats dermatophyte infections, not acute bacterial paronychia with cellulitis."
            },
            {
              "id": "B",
              "text": "Option C: Oral fluconazole is inappropriate because fluconazole is used for selected fungal infections and does not treat this acute bacterial nail-fold infection."
            },
            {
              "id": "C",
              "text": "Option D: Oral ketoconazole is not indicated for bacterial paronychia and has significant toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical terbinafine treats dermatophyte infections, not acute bacterial paronychia with cellulitis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral fluconazole is inappropriate because fluconazole is used for selected fungal infections and does not treat this acute bacterial nail-fold infection."
            },
            {
              "id": "B",
              "text": "Option A: Topical terbinafine treats dermatophyte infections, not acute bacterial paronychia with cellulitis."
            },
            {
              "id": "C",
              "text": "Option D: Oral ketoconazole is not indicated for bacterial paronychia and has significant toxicity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral fluconazole is inappropriate because fluconazole is used for selected fungal infections and does not treat this acute bacterial nail-fold infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral ketoconazole is not indicated for bacterial paronychia and has significant toxicity."
            },
            {
              "id": "B",
              "text": "Option A: Topical terbinafine treats dermatophyte infections, not acute bacterial paronychia with cellulitis."
            },
            {
              "id": "C",
              "text": "Option C: Oral fluconazole is inappropriate because fluconazole is used for selected fungal infections and does not treat this acute bacterial nail-fold infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral ketoconazole is not indicated for bacterial paronychia and has significant toxicity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral penicillin V is inappropriate because penicillin V has unreliable activity against beta-lactamase-producing Staphylococcus aureus, a common cause of acute paronychia."
            },
            {
              "id": "B",
              "text": "Option A: Topical terbinafine treats dermatophyte infections, not acute bacterial paronychia with cellulitis."
            },
            {
              "id": "C",
              "text": "Option C: Oral fluconazole is inappropriate because fluconazole is used for selected fungal infections and does not treat this acute bacterial nail-fold infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral penicillin V is inappropriate because penicillin V has unreliable activity against beta-lactamase-producing Staphylococcus aureus, a common cause of acute paronychia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Incision and drainage of the nail fold is inappropriate because incision and drainage is indicated when paronychia has formed a drainable abscess. The explicit absence of pus and fluctuance makes drainage unnecessary; the spreading nonpurulent cellulitis should instead receive an oral antibacterial agent."
            },
            {
              "id": "B",
              "text": "Option A: Topical terbinafine treats dermatophyte infections, not acute bacterial paronychia with cellulitis."
            },
            {
              "id": "C",
              "text": "Option C: Oral fluconazole is inappropriate because fluconazole is used for selected fungal infections and does not treat this acute bacterial nail-fold infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Incision and drainage of the nail fold is inappropriate because incision and drainage is indicated when paronychia has formed a drainable abscess. The explicit absence of pus and fluctuance makes drainage unnecessary; the spreading nonpurulent cellulitis should instead receive an oral antibacterial agent."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical mupirocin alone is inappropriate because topical therapy alone is inadequate because erythema extends beyond the nail fold onto the finger, indicating cellulitis that requires systemic oral therapy."
            },
            {
              "id": "B",
              "text": "Option A: Topical terbinafine treats dermatophyte infections, not acute bacterial paronychia with cellulitis."
            },
            {
              "id": "C",
              "text": "Option C: Oral fluconazole is inappropriate because fluconazole is used for selected fungal infections and does not treat this acute bacterial nail-fold infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical mupirocin alone is inappropriate because topical therapy alone is inadequate because erythema extends beyond the nail fold onto the finger, indicating cellulitis that requires systemic oral therapy."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral trimethoprim-sulfamethoxazole alone is inappropriate because trimethoprim-sulfamethoxazole alone is not preferred for uncomplicated nonpurulent cellulitis because its activity against beta-hemolytic streptococci is uncertain. There is no purulence or stated MRSA risk to justify substituting MRSA-focused monotherapy for cephalexin."
            },
            {
              "id": "B",
              "text": "Option A: Topical terbinafine treats dermatophyte infections, not acute bacterial paronychia with cellulitis."
            },
            {
              "id": "C",
              "text": "Option C: Oral fluconazole is inappropriate because fluconazole is used for selected fungal infections and does not treat this acute bacterial nail-fold infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral trimethoprim-sulfamethoxazole alone is inappropriate because trimethoprim-sulfamethoxazole alone is not preferred for uncomplicated nonpurulent cellulitis because its activity against beta-hemolytic streptococci is uncertain. There is no purulence or stated MRSA risk to justify substituting MRSA-focused monotherapy for cephalexin."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i011-chylomicronemia-pancreatitis-prevention",
      "expectedHashes": {
        "ranaze_step3_uat": "d8f54b5ff5d691ef9ec4f77fbc6345bff161c050e3459b469ef3ca6ef3380e16",
        "ranaze_step3_prd": "d8f54b5ff5d691ef9ec4f77fbc6345bff161c050e3459b469ef3ca6ef3380e16"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hydrochlorothiazide can worsen hypertriglyceridemia and does not address the immediate pancreatitis risk."
            },
            {
              "id": "B",
              "text": "Option B: Discontinue amlodipine is inappropriate because amlodipine is not a cause of severe hypertriglyceridemia, and stopping effective antihypertensive therapy would not lower triglycerides."
            },
            {
              "id": "C",
              "text": "Option C: Cholestyramine can increase triglyceride concentrations and should be avoided with marked hypertriglyceridemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hydrochlorothiazide can worsen hypertriglyceridemia and does not address the immediate pancreatitis risk."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discontinue amlodipine is inappropriate because amlodipine is not a cause of severe hypertriglyceridemia, and stopping effective antihypertensive therapy would not lower triglycerides."
            },
            {
              "id": "B",
              "text": "Option A: Hydrochlorothiazide can worsen hypertriglyceridemia and does not address the immediate pancreatitis risk."
            },
            {
              "id": "C",
              "text": "Option C: Cholestyramine can increase triglyceride concentrations and should be avoided with marked hypertriglyceridemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discontinue amlodipine is inappropriate because amlodipine is not a cause of severe hypertriglyceridemia, and stopping effective antihypertensive therapy would not lower triglycerides."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cholestyramine can increase triglyceride concentrations and should be avoided with marked hypertriglyceridemia."
            },
            {
              "id": "B",
              "text": "Option A: Hydrochlorothiazide can worsen hypertriglyceridemia and does not address the immediate pancreatitis risk."
            },
            {
              "id": "C",
              "text": "Option B: Discontinue amlodipine is inappropriate because amlodipine is not a cause of severe hypertriglyceridemia, and stopping effective antihypertensive therapy would not lower triglycerides."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cholestyramine can increase triglyceride concentrations and should be avoided with marked hypertriglyceridemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Metformin can be considered for diabetes management but does not address the immediate pancreatitis risk from triglycerides of 1460 mg/dL."
            },
            {
              "id": "B",
              "text": "Option A: Hydrochlorothiazide can worsen hypertriglyceridemia and does not address the immediate pancreatitis risk."
            },
            {
              "id": "C",
              "text": "Option B: Discontinue amlodipine is inappropriate because amlodipine is not a cause of severe hypertriglyceridemia, and stopping effective antihypertensive therapy would not lower triglycerides."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Metformin can be considered for diabetes management but does not address the immediate pancreatitis risk from triglycerides of 1460 mg/dL."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start high-intensity atorvastatin therapy is inappropriate because a statin may later be indicated according to overall atherosclerotic cardiovascular risk, but it is not the best initial monotherapy for triglycerides of 1460 mg/dL. The immediate treatment priority is substantial triglyceride lowering to reduce pancreatitis risk."
            },
            {
              "id": "B",
              "text": "Option A: Hydrochlorothiazide can worsen hypertriglyceridemia and does not address the immediate pancreatitis risk."
            },
            {
              "id": "C",
              "text": "Option B: Discontinue amlodipine is inappropriate because amlodipine is not a cause of severe hypertriglyceridemia, and stopping effective antihypertensive therapy would not lower triglycerides."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start high-intensity atorvastatin therapy is inappropriate because a statin may later be indicated according to overall atherosclerotic cardiovascular risk, but it is not the best initial monotherapy for triglycerides of 1460 mg/dL. The immediate treatment priority is substantial triglyceride lowering to reduce pancreatitis risk."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start extended-release niacin therapy is inappropriate because niacin can lower triglycerides but is not preferred over a fibrate for severe hypertriglyceridemia because of its adverse-effect burden and lack of a role as the most appropriate first-line agent here."
            },
            {
              "id": "B",
              "text": "Option A: Hydrochlorothiazide can worsen hypertriglyceridemia and does not address the immediate pancreatitis risk."
            },
            {
              "id": "C",
              "text": "Option B: Discontinue amlodipine is inappropriate because amlodipine is not a cause of severe hypertriglyceridemia, and stopping effective antihypertensive therapy would not lower triglycerides."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start extended-release niacin therapy is inappropriate because niacin can lower triglycerides but is not preferred over a fibrate for severe hypertriglyceridemia because of its adverse-effect burden and lack of a role as the most appropriate first-line agent here."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i014-prosthetic-joint-infection-management",
      "expectedHashes": {
        "ranaze_step3_uat": "fd27bb7e03ef77dfffb2b55a56be7c01a0c70d79c926245dc216d6353b463a9c",
        "ranaze_step3_prd": "fd27bb7e03ef77dfffb2b55a56be7c01a0c70d79c926245dc216d6353b463a9c"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Duration of symptoms before presentation is inappropriate because symptoms of several weeks help guide the surgical approach but are less important than control of the infected hardware."
            },
            {
              "id": "B",
              "text": "Option C: Negative blood cultures do not exclude a deep prosthetic joint infection and are not the principal prognostic factor."
            },
            {
              "id": "C",
              "text": "Option D: Use of cefazolin rather than another active antibiotic is inappropriate because an active antibiotic is necessary, but antibiotics alone often cannot eradicate infection on retained hardware."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Duration of symptoms before presentation is inappropriate because symptoms of several weeks help guide the surgical approach but are less important than control of the infected hardware."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Negative blood cultures do not exclude a deep prosthetic joint infection and are not the principal prognostic factor."
            },
            {
              "id": "B",
              "text": "Option A: Duration of symptoms before presentation is inappropriate because symptoms of several weeks help guide the surgical approach but are less important than control of the infected hardware."
            },
            {
              "id": "C",
              "text": "Option D: Use of cefazolin rather than another active antibiotic is inappropriate because an active antibiotic is necessary, but antibiotics alone often cannot eradicate infection on retained hardware."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Negative blood cultures do not exclude a deep prosthetic joint infection and are not the principal prognostic factor."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use of cefazolin rather than another active antibiotic is inappropriate because an active antibiotic is necessary, but antibiotics alone often cannot eradicate infection on retained hardware."
            },
            {
              "id": "B",
              "text": "Option A: Duration of symptoms before presentation is inappropriate because symptoms of several weeks help guide the surgical approach but are less important than control of the infected hardware."
            },
            {
              "id": "C",
              "text": "Option C: Negative blood cultures do not exclude a deep prosthetic joint infection and are not the principal prognostic factor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use of cefazolin rather than another active antibiotic is inappropriate because an active antibiotic is necessary, but antibiotics alone often cannot eradicate infection on retained hardware."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patient age is inappropriate because age affects operative risk but is less important than source control."
            },
            {
              "id": "B",
              "text": "Option A: Duration of symptoms before presentation is inappropriate because symptoms of several weeks help guide the surgical approach but are less important than control of the infected hardware."
            },
            {
              "id": "C",
              "text": "Option C: Negative blood cultures do not exclude a deep prosthetic joint infection and are not the principal prognostic factor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patient age is inappropriate because age affects operative risk but is less important than source control."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Virulence of the cultured organism is inappropriate because staphylococcus aureus is a virulent pathogen and can affect relapse risk, but organism identity is subordinate to achieving surgical source control of infected prosthetic material."
            },
            {
              "id": "B",
              "text": "Option A: Duration of symptoms before presentation is inappropriate because symptoms of several weeks help guide the surgical approach but are less important than control of the infected hardware."
            },
            {
              "id": "C",
              "text": "Option C: Negative blood cultures do not exclude a deep prosthetic joint infection and are not the principal prognostic factor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Virulence of the cultured organism is inappropriate because staphylococcus aureus is a virulent pathogen and can affect relapse risk, but organism identity is subordinate to achieving surgical source control of infected prosthetic material."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Duration of intravenous antibiotic therapy is inappropriate because an adequate pathogen-directed antibiotic course is necessary, but extending intravenous therapy cannot reliably compensate for inadequate management of infected hardware."
            },
            {
              "id": "B",
              "text": "Option A: Duration of symptoms before presentation is inappropriate because symptoms of several weeks help guide the surgical approach but are less important than control of the infected hardware."
            },
            {
              "id": "C",
              "text": "Option C: Negative blood cultures do not exclude a deep prosthetic joint infection and are not the principal prognostic factor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Duration of intravenous antibiotic therapy is inappropriate because an adequate pathogen-directed antibiotic course is necessary, but extending intravenous therapy cannot reliably compensate for inadequate management of infected hardware."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i015-nontyphoidal-salmonella-treatment",
      "expectedHashes": {
        "ranaze_step3_uat": "8f851e16e1df817ea9b626215597a7e1d502c1613450ef4d8359aee82316f2a3",
        "ranaze_step3_prd": "8f851e16e1df817ea9b626215597a7e1d502c1613450ef4d8359aee82316f2a3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral azithromycin for 3 days is inappropriate because antibiotics are not indicated after recovery in an immunocompetent child without invasive disease."
            },
            {
              "id": "B",
              "text": "Option C: Oral ciprofloxacin until the stool culture is negative is inappropriate because fluoroquinolones are not used to clear asymptomatic stool carriage after uncomplicated illness."
            },
            {
              "id": "C",
              "text": "Option D: Trimethoprim-sulfamethoxazole for 14 days is inappropriate because prolonged antibiotic therapy is unnecessary and can prolong Salmonella carriage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral azithromycin for 3 days is inappropriate because antibiotics are not indicated after recovery in an immunocompetent child without invasive disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral ciprofloxacin until the stool culture is negative is inappropriate because fluoroquinolones are not used to clear asymptomatic stool carriage after uncomplicated illness."
            },
            {
              "id": "B",
              "text": "Option B: Oral azithromycin for 3 days is inappropriate because antibiotics are not indicated after recovery in an immunocompetent child without invasive disease."
            },
            {
              "id": "C",
              "text": "Option D: Trimethoprim-sulfamethoxazole for 14 days is inappropriate because prolonged antibiotic therapy is unnecessary and can prolong Salmonella carriage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral ciprofloxacin until the stool culture is negative is inappropriate because fluoroquinolones are not used to clear asymptomatic stool carriage after uncomplicated illness."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Trimethoprim-sulfamethoxazole for 14 days is inappropriate because prolonged antibiotic therapy is unnecessary and can prolong Salmonella carriage."
            },
            {
              "id": "B",
              "text": "Option B: Oral azithromycin for 3 days is inappropriate because antibiotics are not indicated after recovery in an immunocompetent child without invasive disease."
            },
            {
              "id": "C",
              "text": "Option C: Oral ciprofloxacin until the stool culture is negative is inappropriate because fluoroquinolones are not used to clear asymptomatic stool carriage after uncomplicated illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Trimethoprim-sulfamethoxazole for 14 days is inappropriate because prolonged antibiotic therapy is unnecessary and can prolong Salmonella carriage."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hospital admission for intravenous ceftriaxone is inappropriate because she has no ongoing dehydration, fever, or evidence of invasive disease requiring hospitalization."
            },
            {
              "id": "B",
              "text": "Option B: Oral azithromycin for 3 days is inappropriate because antibiotics are not indicated after recovery in an immunocompetent child without invasive disease."
            },
            {
              "id": "C",
              "text": "Option C: Oral ciprofloxacin until the stool culture is negative is inappropriate because fluoroquinolones are not used to clear asymptomatic stool carriage after uncomplicated illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hospital admission for intravenous ceftriaxone is inappropriate because she has no ongoing dehydration, fever, or evidence of invasive disease requiring hospitalization."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat stool culture now to document clearance is inappropriate because salmonella can remain detectable in stool for weeks after symptoms resolve. Routine proof of clearance is unnecessary in a recovered child; follow-up culture is generally reserved for prolonged diarrhea or a specific public-health requirement."
            },
            {
              "id": "B",
              "text": "Option B: Oral azithromycin for 3 days is inappropriate because antibiotics are not indicated after recovery in an immunocompetent child without invasive disease."
            },
            {
              "id": "C",
              "text": "Option C: Oral ciprofloxacin until the stool culture is negative is inappropriate because fluoroquinolones are not used to clear asymptomatic stool carriage after uncomplicated illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat stool culture now to document clearance is inappropriate because salmonella can remain detectable in stool for weeks after symptoms resolve. Routine proof of clearance is unnecessary in a recovered child; follow-up culture is generally reserved for prolonged diarrhea or a specific public-health requirement."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain blood cultures to exclude occult bacteremia is inappropriate because blood cultures are appropriate when bacteremia or invasive disease is suspected. This playful, afebrile child has recovered and has no clinical evidence warranting an invasive evaluation."
            },
            {
              "id": "B",
              "text": "Option B: Oral azithromycin for 3 days is inappropriate because antibiotics are not indicated after recovery in an immunocompetent child without invasive disease."
            },
            {
              "id": "C",
              "text": "Option C: Oral ciprofloxacin until the stool culture is negative is inappropriate because fluoroquinolones are not used to clear asymptomatic stool carriage after uncomplicated illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain blood cultures to exclude occult bacteremia is inappropriate because blood cultures are appropriate when bacteremia or invasive disease is suspected. This playful, afebrile child has recovered and has no clinical evidence warranting an invasive evaluation."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Institute a lactose-free diet for 2 weeks is inappropriate because a temporary lactose restriction may be considered for clinically apparent postinfectious lactose intolerance, but she drinks normally and has no ongoing gastrointestinal symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Oral azithromycin for 3 days is inappropriate because antibiotics are not indicated after recovery in an immunocompetent child without invasive disease."
            },
            {
              "id": "C",
              "text": "Option C: Oral ciprofloxacin until the stool culture is negative is inappropriate because fluoroquinolones are not used to clear asymptomatic stool carriage after uncomplicated illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Institute a lactose-free diet for 2 weeks is inappropriate because a temporary lactose restriction may be considered for clinically apparent postinfectious lactose intolerance, but she drinks normally and has no ongoing gastrointestinal symptoms."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i016-congenital-cmv-hearing-loss",
      "expectedHashes": {
        "ranaze_step3_uat": "257e0763cba16bd286d9496b6b1ca7830fc8a7bf4c818235fe51a84299050e16",
        "ranaze_step3_prd": "257e0763cba16bd286d9496b6b1ca7830fc8a7bf4c818235fe51a84299050e16"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Absent thymus is inappropriate because thymic aplasia is associated with 22q11.2 deletion syndrome, not congenital CMV."
            },
            {
              "id": "B",
              "text": "Option C: Pulmonary valve stenosis is inappropriate because pulmonary stenosis is not a typical sequela of congenital CMV infection."
            },
            {
              "id": "C",
              "text": "Option D: Primary congenital hypothyroidism is inappropriate because congenital hypothyroidism is detected by newborn screening and is not the characteristic complication of CMV."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Absent thymus is inappropriate because thymic aplasia is associated with 22q11.2 deletion syndrome, not congenital CMV."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary valve stenosis is inappropriate because pulmonary stenosis is not a typical sequela of congenital CMV infection."
            },
            {
              "id": "B",
              "text": "Option B: Absent thymus is inappropriate because thymic aplasia is associated with 22q11.2 deletion syndrome, not congenital CMV."
            },
            {
              "id": "C",
              "text": "Option D: Primary congenital hypothyroidism is inappropriate because congenital hypothyroidism is detected by newborn screening and is not the characteristic complication of CMV."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary valve stenosis is inappropriate because pulmonary stenosis is not a typical sequela of congenital CMV infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Primary congenital hypothyroidism is inappropriate because congenital hypothyroidism is detected by newborn screening and is not the characteristic complication of CMV."
            },
            {
              "id": "B",
              "text": "Option B: Absent thymus is inappropriate because thymic aplasia is associated with 22q11.2 deletion syndrome, not congenital CMV."
            },
            {
              "id": "C",
              "text": "Option C: Pulmonary valve stenosis is inappropriate because pulmonary stenosis is not a typical sequela of congenital CMV infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Primary congenital hypothyroidism is inappropriate because congenital hypothyroidism is detected by newborn screening and is not the characteristic complication of CMV."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bilateral lens opacities is inappropriate because lens opacities are classically associated with congenital rubella, not CMV."
            },
            {
              "id": "B",
              "text": "Option B: Absent thymus is inappropriate because thymic aplasia is associated with 22q11.2 deletion syndrome, not congenital CMV."
            },
            {
              "id": "C",
              "text": "Option C: Pulmonary valve stenosis is inappropriate because pulmonary stenosis is not a typical sequela of congenital CMV infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bilateral lens opacities is inappropriate because lens opacities are classically associated with congenital rubella, not CMV."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Conductive hearing loss from chronic middle-ear effusions is inappropriate because congenital CMV classically causes sensorineural\u2014not conductive\u2014hearing loss, which may be delayed or progressive."
            },
            {
              "id": "B",
              "text": "Option B: Absent thymus is inappropriate because thymic aplasia is associated with 22q11.2 deletion syndrome, not congenital CMV."
            },
            {
              "id": "C",
              "text": "Option C: Pulmonary valve stenosis is inappropriate because pulmonary stenosis is not a typical sequela of congenital CMV infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Conductive hearing loss from chronic middle-ear effusions is inappropriate because congenital CMV classically causes sensorineural\u2014not conductive\u2014hearing loss, which may be delayed or progressive."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hutchinson teeth are a late manifestation of congenital syphilis. They are not an expected consequence of congenital CMV."
            },
            {
              "id": "B",
              "text": "Option B: Absent thymus is inappropriate because thymic aplasia is associated with 22q11.2 deletion syndrome, not congenital CMV."
            },
            {
              "id": "C",
              "text": "Option C: Pulmonary valve stenosis is inappropriate because pulmonary stenosis is not a typical sequela of congenital CMV infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hutchinson teeth are a late manifestation of congenital syphilis. They are not an expected consequence of congenital CMV."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Limb hypoplasia with cicatricial skin scarring is inappropriate because limb hypoplasia with cicatricial skin lesions is associated with congenital varicella syndrome. CMV-related violaceous papules reflect extramedullary hematopoiesis and do not evolve into that pattern."
            },
            {
              "id": "B",
              "text": "Option B: Absent thymus is inappropriate because thymic aplasia is associated with 22q11.2 deletion syndrome, not congenital CMV."
            },
            {
              "id": "C",
              "text": "Option C: Pulmonary valve stenosis is inappropriate because pulmonary stenosis is not a typical sequela of congenital CMV infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Limb hypoplasia with cicatricial skin scarring is inappropriate because limb hypoplasia with cicatricial skin lesions is associated with congenital varicella syndrome. CMV-related violaceous papules reflect extramedullary hematopoiesis and do not evolve into that pattern."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i018-hepatitis-a-homelessness-prevention",
      "expectedHashes": {
        "ranaze_step3_uat": "db6eb723eab6a183b9c28f13213511327d19ce524cc175a84f9abf91d5c9dfe2",
        "ranaze_step3_prd": "db6eb723eab6a183b9c28f13213511327d19ce524cc175a84f9abf91d5c9dfe2"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "B",
              "text": "Option C: She already received the current seasonal influenza vaccine 2 months ago."
            },
            {
              "id": "C",
              "text": "Option D: A one-time inactivated polio vaccine booster is used for fully vaccinated adults with increased risk of poliovirus exposure, such as certain international travelers; she has no planned international travel."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She already received the current seasonal influenza vaccine 2 months ago."
            },
            {
              "id": "B",
              "text": "Option B: Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "C",
              "text": "Option D: A one-time inactivated polio vaccine booster is used for fully vaccinated adults with increased risk of poliovirus exposure, such as certain international travelers; she has no planned international travel."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She already received the current seasonal influenza vaccine 2 months ago."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A one-time inactivated polio vaccine booster is used for fully vaccinated adults with increased risk of poliovirus exposure, such as certain international travelers; she has no planned international travel."
            },
            {
              "id": "B",
              "text": "Option B: Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "C",
              "text": "Option C: She already received the current seasonal influenza vaccine 2 months ago."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A one-time inactivated polio vaccine booster is used for fully vaccinated adults with increased risk of poliovirus exposure, such as certain international travelers; she has no planned international travel."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Rabies preexposure vaccine is inappropriate because rabies preexposure vaccination is generally reserved for people with substantial anticipated animal exposure or certain occupational risks."
            },
            {
              "id": "B",
              "text": "Option B: Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "C",
              "text": "Option C: She already received the current seasonal influenza vaccine 2 months ago."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Rabies preexposure vaccine is inappropriate because rabies preexposure vaccination is generally reserved for people with substantial anticipated animal exposure or certain occupational risks."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Meningococcal conjugate vaccine (MenACWY) is inappropriate because congregate shelter residence can suggest meningococcal vaccination, but homelessness alone is not a routine MenACWY indication. Adult indications include asplenia, complement deficiency or inhibitor use, HIV, specified travel or laboratory exposure, military recruitment, and certain first-year college housing."
            },
            {
              "id": "B",
              "text": "Option B: Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "C",
              "text": "Option C: She already received the current seasonal influenza vaccine 2 months ago."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Meningococcal conjugate vaccine (MenACWY) is inappropriate because congregate shelter residence can suggest meningococcal vaccination, but homelessness alone is not a routine MenACWY indication. Adult indications include asplenia, complement deficiency or inhibitor use, HIV, specified travel or laboratory exposure, military recruitment, and certain first-year college housing."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recombinant zoster vaccine is inappropriate because routine recombinant zoster vaccination begins at age 50, or at age 19 for adults who are or will be immunocompromised. This healthy 38-year-old meets neither criterion."
            },
            {
              "id": "B",
              "text": "Option B: Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "C",
              "text": "Option C: She already received the current seasonal influenza vaccine 2 months ago."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recombinant zoster vaccine is inappropriate because routine recombinant zoster vaccination begins at age 50, or at age 19 for adults who are or will be immunocompromised. This healthy 38-year-old meets neither criterion."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pneumococcal conjugate vaccine is inappropriate because current routine pneumococcal vaccination applies beginning at age 50 or earlier for specified risk conditions. This 38-year-old has no listed medical risk condition."
            },
            {
              "id": "B",
              "text": "Option B: Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "C",
              "text": "Option C: She already received the current seasonal influenza vaccine 2 months ago."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pneumococcal conjugate vaccine is inappropriate because current routine pneumococcal vaccination applies beginning at age 50 or earlier for specified risk conditions. This 38-year-old has no listed medical risk condition."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Typhoid vaccine is principally recommended for travelers to areas with recognized typhoid exposure risk and certain laboratory workers. She has no international travel plans or relevant occupational exposure."
            },
            {
              "id": "B",
              "text": "Option B: Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "C",
              "text": "Option C: She already received the current seasonal influenza vaccine 2 months ago."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Typhoid vaccine is principally recommended for travelers to areas with recognized typhoid exposure risk and certain laboratory workers. She has no international travel plans or relevant occupational exposure."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measles-mumps-rubella vaccine booster is inappropriate because an additional MMR dose is not routinely indicated when an adult has already completed the routine immunization series and has no stated outbreak, travel, or other special-risk indication."
            },
            {
              "id": "B",
              "text": "Option B: Oral cholera vaccine is inappropriate because cholera vaccine is not routinely indicated for a patient without travel to an area with active cholera transmission or another high-risk exposure."
            },
            {
              "id": "C",
              "text": "Option C: She already received the current seasonal influenza vaccine 2 months ago."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measles-mumps-rubella vaccine booster is inappropriate because an additional MMR dose is not routinely indicated when an adult has already completed the routine immunization series and has no stated outbreak, travel, or other special-risk indication."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i019-febrile-transfusion-reaction-prevention",
      "expectedHashes": {
        "ranaze_step3_uat": "aab481962d9a4b1cf31125c53c208fd09cd3404e4b308b627d5f7caaf43a6a20",
        "ranaze_step3_prd": "aab481962d9a4b1cf31125c53c208fd09cd3404e4b308b627d5f7caaf43a6a20"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "B",
              "text": "Option C: Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            },
            {
              "id": "C",
              "text": "Option D: Use frozen, deglycerolized red blood cells is inappropriate because frozen, deglycerolized cells are used in limited circumstances, such as special blood storage needs, and are not standard prevention for this reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            },
            {
              "id": "B",
              "text": "Option B: Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "C",
              "text": "Option D: Use frozen, deglycerolized red blood cells is inappropriate because frozen, deglycerolized cells are used in limited circumstances, such as special blood storage needs, and are not standard prevention for this reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use frozen, deglycerolized red blood cells is inappropriate because frozen, deglycerolized cells are used in limited circumstances, such as special blood storage needs, and are not standard prevention for this reaction."
            },
            {
              "id": "B",
              "text": "Option B: Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "C",
              "text": "Option C: Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use frozen, deglycerolized red blood cells is inappropriate because frozen, deglycerolized cells are used in limited circumstances, such as special blood storage needs, and are not standard prevention for this reaction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer prophylactic antibiotics before transfusion is inappropriate because antibiotics do not prevent febrile nonhemolytic transfusion reactions."
            },
            {
              "id": "B",
              "text": "Option B: Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "C",
              "text": "Option C: Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer prophylactic antibiotics before transfusion is inappropriate because antibiotics do not prevent febrile nonhemolytic transfusion reactions."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer diphenhydramine before each transfusion is inappropriate because diphenhydramine targets histamine-mediated allergic symptoms. This reaction consists of fever and rigors without rash or dyspnea, so antihistamine premedication does not address its mechanism."
            },
            {
              "id": "B",
              "text": "Option B: Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "C",
              "text": "Option C: Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer diphenhydramine before each transfusion is inappropriate because diphenhydramine targets histamine-mediated allergic symptoms. This reaction consists of fever and rigors without rash or dyspnea, so antihistamine premedication does not address its mechanism."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfuse red blood cells at a slower rate is inappropriate because a slower rate may help with circulatory-overload risk but does not remove donor leukocytes or accumulated cytokines and therefore is not the appropriate strategy for recurrent febrile nonhemolytic reactions."
            },
            {
              "id": "B",
              "text": "Option B: Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "C",
              "text": "Option C: Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfuse red blood cells at a slower rate is inappropriate because a slower rate may help with circulatory-overload risk but does not remove donor leukocytes or accumulated cytokines and therefore is not the appropriate strategy for recurrent febrile nonhemolytic reactions."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use warmed red blood cells is inappropriate because blood warming is used for settings such as clinically significant cold agglutinins or rapid massive transfusion. This patient has no clinical or laboratory evidence of hemolysis, and warming does not prevent febrile nonhemolytic reactions."
            },
            {
              "id": "B",
              "text": "Option B: Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "C",
              "text": "Option C: Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use warmed red blood cells is inappropriate because blood warming is used for settings such as clinically significant cold agglutinins or rapid massive transfusion. This patient has no clinical or laboratory evidence of hemolysis, and warming does not prevent febrile nonhemolytic reactions."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use CMV-seronegative red blood cells is inappropriate because cMV-seronegative components reduce transfusion-transmitted CMV risk in selected susceptible recipients. They do not prevent an acute fever-and-rigors reaction caused by donor leukocytes or inflammatory cytokines."
            },
            {
              "id": "B",
              "text": "Option B: Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "C",
              "text": "Option C: Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use CMV-seronegative red blood cells is inappropriate because cMV-seronegative components reduce transfusion-transmitted CMV risk in selected susceptible recipients. They do not prevent an acute fever-and-rigors reaction caused by donor leukocytes or inflammatory cytokines."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use exclusively ABO-identical red blood cells is inappropriate because aBO-identical selection addresses ABO incompatibility, but this patient has a negative direct antiglobulin test and normal hemolysis markers. ABO selection does not replace leukoreduction for preventing recurrent febrile nonhemolytic reactions."
            },
            {
              "id": "B",
              "text": "Option B: Use washed red blood cells is inappropriate because washed red blood cells are primarily used for recurrent severe allergic reactions caused by donor plasma proteins."
            },
            {
              "id": "C",
              "text": "Option C: Use irradiated red blood cells is inappropriate because irradiation prevents transfusion-associated graft-versus-host disease in susceptible recipients; it does not prevent febrile nonhemolytic reactions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use exclusively ABO-identical red blood cells is inappropriate because aBO-identical selection addresses ABO incompatibility, but this patient has a negative direct antiglobulin test and normal hemolysis markers. ABO selection does not replace leukoreduction for preventing recurrent febrile nonhemolytic reactions."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i020-arthroplasty-vte-prophylaxis",
      "expectedHashes": {
        "ranaze_step3_uat": "ff0dfcc8929a933bd49270742079c27daec74b384e4208072cd57517b82bb98d",
        "ranaze_step3_prd": "ff0dfcc8929a933bd49270742079c27daec74b384e4208072cd57517b82bb98d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elastic compression stockings alone is inappropriate because elastic stockings alone provide insufficient prophylaxis for the high thrombotic risk of total hip arthroplasty when anticoagulation is safe."
            },
            {
              "id": "B",
              "text": "Option C: Continuous intravenous unfractionated heparin is inappropriate because continuous intravenous heparin is therapeutic anticoagulation and is not used for routine surgical prophylaxis."
            },
            {
              "id": "C",
              "text": "Option D: Sequential compression devices alone is inappropriate because sequential compression devices are useful adjuncts but are inadequate as sole prophylaxis in this patient without a bleeding contraindication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elastic compression stockings alone is inappropriate because elastic stockings alone provide insufficient prophylaxis for the high thrombotic risk of total hip arthroplasty when anticoagulation is safe."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continuous intravenous unfractionated heparin is inappropriate because continuous intravenous heparin is therapeutic anticoagulation and is not used for routine surgical prophylaxis."
            },
            {
              "id": "B",
              "text": "Option B: Elastic compression stockings alone is inappropriate because elastic stockings alone provide insufficient prophylaxis for the high thrombotic risk of total hip arthroplasty when anticoagulation is safe."
            },
            {
              "id": "C",
              "text": "Option D: Sequential compression devices alone is inappropriate because sequential compression devices are useful adjuncts but are inadequate as sole prophylaxis in this patient without a bleeding contraindication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continuous intravenous unfractionated heparin is inappropriate because continuous intravenous heparin is therapeutic anticoagulation and is not used for routine surgical prophylaxis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sequential compression devices alone is inappropriate because sequential compression devices are useful adjuncts but are inadequate as sole prophylaxis in this patient without a bleeding contraindication."
            },
            {
              "id": "B",
              "text": "Option B: Elastic compression stockings alone is inappropriate because elastic stockings alone provide insufficient prophylaxis for the high thrombotic risk of total hip arthroplasty when anticoagulation is safe."
            },
            {
              "id": "C",
              "text": "Option C: Continuous intravenous unfractionated heparin is inappropriate because continuous intravenous heparin is therapeutic anticoagulation and is not used for routine surgical prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sequential compression devices alone is inappropriate because sequential compression devices are useful adjuncts but are inadequate as sole prophylaxis in this patient without a bleeding contraindication."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcutaneous low-dose unfractionated heparin is inappropriate because low-dose unfractionated heparin is an alternative in some settings, but low-molecular-weight heparin is preferred for this high-risk orthopedic procedure."
            },
            {
              "id": "B",
              "text": "Option B: Elastic compression stockings alone is inappropriate because elastic stockings alone provide insufficient prophylaxis for the high thrombotic risk of total hip arthroplasty when anticoagulation is safe."
            },
            {
              "id": "C",
              "text": "Option C: Continuous intravenous unfractionated heparin is inappropriate because continuous intravenous heparin is therapeutic anticoagulation and is not used for routine surgical prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcutaneous low-dose unfractionated heparin is inappropriate because low-dose unfractionated heparin is an alternative in some settings, but low-molecular-weight heparin is preferred for this high-risk orthopedic procedure."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Early ambulation without pharmacologic prophylaxis is inappropriate because early ambulation is beneficial but does not replace antithrombotic prophylaxis after total hip arthroplasty in a patient whose normal platelet count, coagulation studies, and creatinine provide no evident contraindication."
            },
            {
              "id": "B",
              "text": "Option B: Elastic compression stockings alone is inappropriate because elastic stockings alone provide insufficient prophylaxis for the high thrombotic risk of total hip arthroplasty when anticoagulation is safe."
            },
            {
              "id": "C",
              "text": "Option C: Continuous intravenous unfractionated heparin is inappropriate because continuous intravenous heparin is therapeutic anticoagulation and is not used for routine surgical prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Early ambulation without pharmacologic prophylaxis is inappropriate because early ambulation is beneficial but does not replace antithrombotic prophylaxis after total hip arthroplasty in a patient whose normal platelet count, coagulation studies, and creatinine provide no evident contraindication."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Preoperative placement of an inferior vena cava filter is inappropriate because prophylactic inferior vena cava filter placement is not recommended for major surgery. This patient has neither established venous thromboembolism nor a contraindication to anticoagulation."
            },
            {
              "id": "B",
              "text": "Option B: Elastic compression stockings alone is inappropriate because elastic stockings alone provide insufficient prophylaxis for the high thrombotic risk of total hip arthroplasty when anticoagulation is safe."
            },
            {
              "id": "C",
              "text": "Option C: Continuous intravenous unfractionated heparin is inappropriate because continuous intravenous heparin is therapeutic anticoagulation and is not used for routine surgical prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Preoperative placement of an inferior vena cava filter is inappropriate because prophylactic inferior vena cava filter placement is not recommended for major surgery. This patient has neither established venous thromboembolism nor a contraindication to anticoagulation."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i022-acute-liver-failure-prognosis",
      "expectedHashes": {
        "ranaze_step3_uat": "c5a0b03b43a0fa4ef34dae4bcb79688bb190148decc38d446c2bbaa2c8e3b9e1",
        "ranaze_step3_prd": "c5a0b03b43a0fa4ef34dae4bcb79688bb190148decc38d446c2bbaa2c8e3b9e1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Marked elevation of serum aminotransferases is inappropriate because aminotransferase levels reflect hepatocyte injury but do not reliably measure residual hepatic synthetic function or prognosis."
            },
            {
              "id": "B",
              "text": "Option C: Elevated total bilirubin concentration is inappropriate because bilirubin reflects impaired excretion but is less predictive of mortality than the degree of coagulopathy."
            },
            {
              "id": "C",
              "text": "Option D: Mild asterixis on examination is inappropriate because asterixis supports hepatic encephalopathy, but the severity of coagulopathy is a stronger prognostic indicator."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Marked elevation of serum aminotransferases is inappropriate because aminotransferase levels reflect hepatocyte injury but do not reliably measure residual hepatic synthetic function or prognosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elevated total bilirubin concentration is inappropriate because bilirubin reflects impaired excretion but is less predictive of mortality than the degree of coagulopathy."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of serum aminotransferases is inappropriate because aminotransferase levels reflect hepatocyte injury but do not reliably measure residual hepatic synthetic function or prognosis."
            },
            {
              "id": "C",
              "text": "Option D: Mild asterixis on examination is inappropriate because asterixis supports hepatic encephalopathy, but the severity of coagulopathy is a stronger prognostic indicator."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elevated total bilirubin concentration is inappropriate because bilirubin reflects impaired excretion but is less predictive of mortality than the degree of coagulopathy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mild asterixis on examination is inappropriate because asterixis supports hepatic encephalopathy, but the severity of coagulopathy is a stronger prognostic indicator."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of serum aminotransferases is inappropriate because aminotransferase levels reflect hepatocyte injury but do not reliably measure residual hepatic synthetic function or prognosis."
            },
            {
              "id": "C",
              "text": "Option C: Elevated total bilirubin concentration is inappropriate because bilirubin reflects impaired excretion but is less predictive of mortality than the degree of coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mild asterixis on examination is inappropriate because asterixis supports hepatic encephalopathy, but the severity of coagulopathy is a stronger prognostic indicator."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mild thrombocytopenia is nonspecific and does not prognosticate acute liver failure as well as INR."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of serum aminotransferases is inappropriate because aminotransferase levels reflect hepatocyte injury but do not reliably measure residual hepatic synthetic function or prognosis."
            },
            {
              "id": "C",
              "text": "Option C: Elevated total bilirubin concentration is inappropriate because bilirubin reflects impaired excretion but is less predictive of mortality than the degree of coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mild thrombocytopenia is nonspecific and does not prognosticate acute liver failure as well as INR."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No history of chronic liver disease is inappropriate because the absence of known chronic liver disease helps establish that this is acute liver failure, but it is diagnostic context rather than the strongest poor-prognosis marker. The markedly prolonged INR directly reflects severe synthetic failure."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of serum aminotransferases is inappropriate because aminotransferase levels reflect hepatocyte injury but do not reliably measure residual hepatic synthetic function or prognosis."
            },
            {
              "id": "C",
              "text": "Option C: Elevated total bilirubin concentration is inappropriate because bilirubin reflects impaired excretion but is less predictive of mortality than the degree of coagulopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No history of chronic liver disease is inappropriate because the absence of known chronic liver disease helps establish that this is acute liver failure, but it is diagnostic context rather than the strongest poor-prognosis marker. The markedly prolonged INR directly reflects severe synthetic failure."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i023-isolated-late-onset-breast-cancer-counseling",
      "expectedHashes": {
        "ranaze_step3_uat": "ca1effd1b033ce933d271045b41941a6eb27c7a4e3b63e6ea906a3d63a682362",
        "ranaze_step3_prd": "ca1effd1b033ce933d271045b41941a6eb27c7a4e3b63e6ea906a3d63a682362"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order BRCA1 and BRCA2 testing for the daughter now is inappropriate because bRCA testing is not indicated solely for one breast cancer diagnosed at advanced age in a third-degree relative."
            },
            {
              "id": "B",
              "text": "Option B: Classify the daughter as having a high-penetrance hereditary breast cancer syndrome is inappropriate because this limited family history does not establish a high-penetrance hereditary cancer syndrome."
            },
            {
              "id": "C",
              "text": "Option C: Begin annual breast MRI in addition to mammography because of her family history is inappropriate because breast MRI is reserved for patients with substantially elevated lifetime risk, such as those with a pathogenic variant or a strongly suggestive family history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order BRCA1 and BRCA2 testing for the daughter now is inappropriate because bRCA testing is not indicated solely for one breast cancer diagnosed at advanced age in a third-degree relative."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Classify the daughter as having a high-penetrance hereditary breast cancer syndrome is inappropriate because this limited family history does not establish a high-penetrance hereditary cancer syndrome."
            },
            {
              "id": "B",
              "text": "Option A: Order BRCA1 and BRCA2 testing for the daughter now is inappropriate because bRCA testing is not indicated solely for one breast cancer diagnosed at advanced age in a third-degree relative."
            },
            {
              "id": "C",
              "text": "Option C: Begin annual breast MRI in addition to mammography because of her family history is inappropriate because breast MRI is reserved for patients with substantially elevated lifetime risk, such as those with a pathogenic variant or a strongly suggestive family history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Classify the daughter as having a high-penetrance hereditary breast cancer syndrome is inappropriate because this limited family history does not establish a high-penetrance hereditary cancer syndrome."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin annual breast MRI in addition to mammography because of her family history is inappropriate because breast MRI is reserved for patients with substantially elevated lifetime risk, such as those with a pathogenic variant or a strongly suggestive family history."
            },
            {
              "id": "B",
              "text": "Option A: Order BRCA1 and BRCA2 testing for the daughter now is inappropriate because bRCA testing is not indicated solely for one breast cancer diagnosed at advanced age in a third-degree relative."
            },
            {
              "id": "C",
              "text": "Option B: Classify the daughter as having a high-penetrance hereditary breast cancer syndrome is inappropriate because this limited family history does not establish a high-penetrance hereditary cancer syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin annual breast MRI in addition to mammography because of her family history is inappropriate because breast MRI is reserved for patients with substantially elevated lifetime risk, such as those with a pathogenic variant or a strongly suggestive family history."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Test the daughter\u0027s children for BRCA mutations is inappropriate because testing children for an adult-onset hereditary cancer syndrome is not appropriate in this setting, particularly when the family history does not indicate testing of their mother."
            },
            {
              "id": "B",
              "text": "Option A: Order BRCA1 and BRCA2 testing for the daughter now is inappropriate because bRCA testing is not indicated solely for one breast cancer diagnosed at advanced age in a third-degree relative."
            },
            {
              "id": "C",
              "text": "Option B: Classify the daughter as having a high-penetrance hereditary breast cancer syndrome is inappropriate because this limited family history does not establish a high-penetrance hereditary cancer syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Test the daughter\u0027s children for BRCA mutations is inappropriate because testing children for an adult-onset hereditary cancer syndrome is not appropriate in this setting, particularly when the family history does not indicate testing of their mother."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange BRCA1 and BRCA2 testing of the affected great-aunt before advising the daughter is inappropriate because when hereditary testing is clinically indicated, testing generally begins with an affected relative. However, one third-degree relative with breast cancer at age 82 and no associated cancer cluster does not itself create an indication to initiate family genetic testing."
            },
            {
              "id": "B",
              "text": "Option A: Order BRCA1 and BRCA2 testing for the daughter now is inappropriate because bRCA testing is not indicated solely for one breast cancer diagnosed at advanced age in a third-degree relative."
            },
            {
              "id": "C",
              "text": "Option B: Classify the daughter as having a high-penetrance hereditary breast cancer syndrome is inappropriate because this limited family history does not establish a high-penetrance hereditary cancer syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange BRCA1 and BRCA2 testing of the affected great-aunt before advising the daughter is inappropriate because when hereditary testing is clinically indicated, testing generally begins with an affected relative. However, one third-degree relative with breast cancer at age 82 and no associated cancer cluster does not itself create an indication to initiate family genetic testing."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin tamoxifen for primary prevention of breast cancer is inappropriate because risk-reducing endocrine medication is considered after formal assessment demonstrates increased breast cancer risk and the expected benefit outweighs medication harms. A single late-onset cancer in a third-degree relative does not establish such eligibility."
            },
            {
              "id": "B",
              "text": "Option A: Order BRCA1 and BRCA2 testing for the daughter now is inappropriate because bRCA testing is not indicated solely for one breast cancer diagnosed at advanced age in a third-degree relative."
            },
            {
              "id": "C",
              "text": "Option B: Classify the daughter as having a high-penetrance hereditary breast cancer syndrome is inappropriate because this limited family history does not establish a high-penetrance hereditary cancer syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin tamoxifen for primary prevention of breast cancer is inappropriate because risk-reducing endocrine medication is considered after formal assessment demonstrates increased breast cancer risk and the expected benefit outweighs medication harms. A single late-onset cancer in a third-degree relative does not establish such eligibility."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform annual screening breast ultrasonography until the daughter reaches the usual age for mammography is inappropriate because ultrasonography is not a substitute for routine mammographic screening and is not recommended as a stand-alone screening strategy solely because of this limited family history."
            },
            {
              "id": "B",
              "text": "Option A: Order BRCA1 and BRCA2 testing for the daughter now is inappropriate because bRCA testing is not indicated solely for one breast cancer diagnosed at advanced age in a third-degree relative."
            },
            {
              "id": "C",
              "text": "Option B: Classify the daughter as having a high-penetrance hereditary breast cancer syndrome is inappropriate because this limited family history does not establish a high-penetrance hereditary cancer syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform annual screening breast ultrasonography until the daughter reaches the usual age for mammography is inappropriate because ultrasonography is not a substitute for routine mammographic screening and is not recommended as a stand-alone screening strategy solely because of this limited family history."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i026-stemi-shock-vasopressor",
      "expectedHashes": {
        "ranaze_step3_uat": "124842db7fc00fe1120aa267cb210d8b542aad643cbaa2fe48f272d5d3a68b16",
        "ranaze_step3_prd": "124842db7fc00fe1120aa267cb210d8b542aad643cbaa2fe48f272d5d3a68b16"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            },
            {
              "id": "C",
              "text": "Option D: Additional chewable aspirin is inappropriate because additional aspirin is unnecessary because chewable aspirin was already administered by paramedics and does not treat the current shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option D: Additional chewable aspirin is inappropriate because additional aspirin is unnecessary because chewable aspirin was already administered by paramedics and does not treat the current shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Additional chewable aspirin is inappropriate because additional aspirin is unnecessary because chewable aspirin was already administered by paramedics and does not treat the current shock."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Additional chewable aspirin is inappropriate because additional aspirin is unnecessary because chewable aspirin was already administered by paramedics and does not treat the current shock."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous verapamil has negative inotropic effects and can worsen severe hypotension."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous verapamil has negative inotropic effects and can worsen severe hypotension."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous dobutamine infusion alone is inappropriate because dobutamine is an inotrope with vasodilatory effects. Given the profound hypotension of 78/50 mm Hg, using it alone can further reduce systemic vascular resistance; pressure should first be supported with norepinephrine."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous dobutamine infusion alone is inappropriate because dobutamine is an inotrope with vasodilatory effects. Given the profound hypotension of 78/50 mm Hg, using it alone can further reduce systemic vascular resistance; pressure should first be supported with norepinephrine."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous phenylephrine infusion is inappropriate because phenylephrine provides pure alpha-adrenergic vasoconstriction without direct inotropic support and can increase afterload while reducing stroke volume, making it a poor choice for pump-failure shock."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous phenylephrine infusion is inappropriate because phenylephrine provides pure alpha-adrenergic vasoconstriction without direct inotropic support and can increase afterload while reducing stroke volume, making it a poor choice for pump-failure shock."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sublingual nitroglycerin is inappropriate because nitroglycerin reduces preload and blood pressure. It is contraindicated in marked hypotension and particularly hazardous in preload-dependent right ventricular infarction."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sublingual nitroglycerin is inappropriate because nitroglycerin reduces preload and blood pressure. It is contraindicated in marked hypotension and particularly hazardous in preload-dependent right ventricular infarction."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous furosemide is inappropriate because furosemide reduces intravascular volume and preload. This patient has clear lungs and right ventricular infarction rather than pulmonary congestion, so diuresis can aggravate hypotension."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous furosemide is inappropriate because furosemide reduces intravascular volume and preload. This patient has clear lungs and right ventricular infarction rather than pulmonary congestion, so diuresis can aggravate hypotension."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous unfractionated heparin is inappropriate because unfractionated heparin may be used as antithrombotic therapy during the invasive STEMI strategy, but it does not promptly restore perfusion pressure and therefore is not the pharmacotherapy requested for the current hemodynamic instability."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous unfractionated heparin is inappropriate because unfractionated heparin may be used as antithrombotic therapy during the invasive STEMI strategy, but it does not promptly restore perfusion pressure and therefore is not the pharmacotherapy requested for the current hemodynamic instability."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous morphine is inappropriate because morphine may relieve refractory ischemic pain but can cause venodilation and hypotension. It neither supports circulation nor substitutes for a vasopressor in cardiogenic shock."
            },
            {
              "id": "B",
              "text": "Option B: Intravenous metoprolol decreases cardiac output and can worsen hypotension in cardiogenic shock."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous tenecteplase is inappropriate because tenecteplase is not preferred because primary PCI can be initiated promptly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous morphine is inappropriate because morphine may relieve refractory ischemic pain but can cause venodilation and hypotension. It neither supports circulation nor substitutes for a vasopressor in cardiogenic shock."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i027-secondary-postpartum-hemorrhage",
      "expectedHashes": {
        "ranaze_step3_uat": "7094c2c9dc2ad9107939448ac3264e82830ae3e8ed813bc8bfc0886f7fe1ba61",
        "ranaze_step3_prd": "7094c2c9dc2ad9107939448ac3264e82830ae3e8ed813bc8bfc0886f7fe1ba61"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
            },
            {
              "id": "B",
              "text": "Option B: Endometrial biopsy is not indicated for acute postpartum bleeding."
            },
            {
              "id": "C",
              "text": "Option C: High-dose estrogen therapy is inappropriate because high-dose estrogen is not appropriate before evaluating a postpartum uterine cause of bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Endometrial biopsy is not indicated for acute postpartum bleeding."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
            },
            {
              "id": "C",
              "text": "Option C: High-dose estrogen therapy is inappropriate because high-dose estrogen is not appropriate before evaluating a postpartum uterine cause of bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Endometrial biopsy is not indicated for acute postpartum bleeding."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose estrogen therapy is inappropriate because high-dose estrogen is not appropriate before evaluating a postpartum uterine cause of bleeding."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
            },
            {
              "id": "C",
              "text": "Option B: Endometrial biopsy is not indicated for acute postpartum bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose estrogen therapy is inappropriate because high-dose estrogen is not appropriate before evaluating a postpartum uterine cause of bleeding."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassurance and observation alone is inappropriate because observation alone is inappropriate because bleeding persists and the uterus is larger than expected."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
            },
            {
              "id": "C",
              "text": "Option B: Endometrial biopsy is not indicated for acute postpartum bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassurance and observation alone is inappropriate because observation alone is inappropriate because bleeding persists and the uterus is larger than expected."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum quantitative beta-hCG measurement is inappropriate because beta-hCG may remain detectable after delivery and is neither sufficiently specific nor the preferred initial test for suspected retained products of conception. The enlarged uterus should be assessed directly with ultrasonography."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
            },
            {
              "id": "C",
              "text": "Option B: Endometrial biopsy is not indicated for acute postpartum bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum quantitative beta-hCG measurement is inappropriate because beta-hCG may remain detectable after delivery and is neither sufficiently specific nor the preferred initial test for suspected retained products of conception. The enlarged uterus should be assessed directly with ultrasonography."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the pelvis is inappropriate because mRI can characterize selected indeterminate pelvic abnormalities but is not the first study for late postpartum bleeding after vaginal delivery. Ultrasonography is faster and is rated usually appropriate for initial imaging."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
            },
            {
              "id": "C",
              "text": "Option B: Endometrial biopsy is not indicated for acute postpartum bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the pelvis is inappropriate because mRI can characterize selected indeterminate pelvic abnormalities but is not the first study for late postpartum bleeding after vaginal delivery. Ultrasonography is faster and is rated usually appropriate for initial imaging."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diagnostic hysteroscopy is inappropriate because hysteroscopy is invasive and may have a therapeutic role after a uterine lesion is identified, but it is not the initial evaluation before pelvic ultrasonography."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
            },
            {
              "id": "C",
              "text": "Option B: Endometrial biopsy is not indicated for acute postpartum bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diagnostic hysteroscopy is inappropriate because hysteroscopy is invasive and may have a therapeutic role after a uterine lesion is identified, but it is not the initial evaluation before pelvic ultrasonography."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate dilation and curettage without imaging is inappropriate because uterine evacuation may be indicated if retained products are confirmed or bleeding becomes severe, but blind immediate curettage without imaging risks unnecessary instrumentation and hemorrhage from a vascular lesion."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the pelvis is inappropriate because cT of the pelvis is not the initial study for suspected intrauterine retained tissue."
            },
            {
              "id": "C",
              "text": "Option B: Endometrial biopsy is not indicated for acute postpartum bleeding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate dilation and curettage without imaging is inappropriate because uterine evacuation may be indicated if retained products are confirmed or bleeding becomes severe, but blind immediate curettage without imaging risks unnecessary instrumentation and hemorrhage from a vascular lesion."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i028-painful-bone-metastases",
      "expectedHashes": {
        "ranaze_step3_uat": "20eb63d82ba10bc6ef4833cf4319d64ce4adbe2be07fc2de6ed3ca2bf85a411a",
        "ranaze_step3_prd": "20eb63d82ba10bc6ef4833cf4319d64ce4adbe2be07fc2de6ed3ca2bf85a411a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acupuncture may be adjunctive for some chronic pain conditions but is not adequate treatment for severe focal pain from bone metastases."
            },
            {
              "id": "B",
              "text": "Option B: Cervical cordotomy is reserved for selected patients with refractory unilateral pain, usually when less invasive therapies have failed."
            },
            {
              "id": "C",
              "text": "Option C: Epidural analgesia can be used for refractory cancer pain but does not provide the local tumor-directed palliation offered by radiation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acupuncture may be adjunctive for some chronic pain conditions but is not adequate treatment for severe focal pain from bone metastases."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cervical cordotomy is reserved for selected patients with refractory unilateral pain, usually when less invasive therapies have failed."
            },
            {
              "id": "B",
              "text": "Option A: Acupuncture may be adjunctive for some chronic pain conditions but is not adequate treatment for severe focal pain from bone metastases."
            },
            {
              "id": "C",
              "text": "Option C: Epidural analgesia can be used for refractory cancer pain but does not provide the local tumor-directed palliation offered by radiation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cervical cordotomy is reserved for selected patients with refractory unilateral pain, usually when less invasive therapies have failed."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Epidural analgesia can be used for refractory cancer pain but does not provide the local tumor-directed palliation offered by radiation."
            },
            {
              "id": "B",
              "text": "Option A: Acupuncture may be adjunctive for some chronic pain conditions but is not adequate treatment for severe focal pain from bone metastases."
            },
            {
              "id": "C",
              "text": "Option B: Cervical cordotomy is reserved for selected patients with refractory unilateral pain, usually when less invasive therapies have failed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Epidural analgesia can be used for refractory cancer pain but does not provide the local tumor-directed palliation offered by radiation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transcutaneous electrical nerve stimulation is inappropriate because tENS is not sufficient treatment for severe pain caused by metastatic bone lesions."
            },
            {
              "id": "B",
              "text": "Option A: Acupuncture may be adjunctive for some chronic pain conditions but is not adequate treatment for severe focal pain from bone metastases."
            },
            {
              "id": "C",
              "text": "Option B: Cervical cordotomy is reserved for selected patients with refractory unilateral pain, usually when less invasive therapies have failed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transcutaneous electrical nerve stimulation is inappropriate because tENS is not sufficient treatment for severe pain caused by metastatic bone lesions."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-dose intravenous dexamethasone is inappropriate because high-dose dexamethasone is indicated when metastatic spinal cord or cauda equina compression is suspected. This patient has pelvic lesions without weakness, sensory loss, or bowel or bladder dysfunction."
            },
            {
              "id": "B",
              "text": "Option A: Acupuncture may be adjunctive for some chronic pain conditions but is not adequate treatment for severe focal pain from bone metastases."
            },
            {
              "id": "C",
              "text": "Option B: Cervical cordotomy is reserved for selected patients with refractory unilateral pain, usually when less invasive therapies have failed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-dose intravenous dexamethasone is inappropriate because high-dose dexamethasone is indicated when metastatic spinal cord or cauda equina compression is suspected. This patient has pelvic lesions without weakness, sensory loss, or bowel or bladder dysfunction."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i029-elevated-blood-pressure-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "baf32310527a862325d69b7bf6218d3316c21c26cfac69440dd39ee32a5d1708",
        "ranaze_step3_prd": "baf32310527a862325d69b7bf6218d3316c21c26cfac69440dd39ee32a5d1708"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Her reported intake of one or two alcoholic beverages on weekends does not suggest the greatest risk is alcohol use disorder."
            },
            {
              "id": "B",
              "text": "Option B: Hypercholesterolemia is inappropriate because a family history of hyperlipidemia is relevant, but her current elevated blood pressure most strongly predicts future hypertension."
            },
            {
              "id": "C",
              "text": "Option D: Obesity is inappropriate because her BMI is normal, and the vignette provides no evidence of excess caloric intake or progressive weight gain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Her reported intake of one or two alcoholic beverages on weekends does not suggest the greatest risk is alcohol use disorder."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hypercholesterolemia is inappropriate because a family history of hyperlipidemia is relevant, but her current elevated blood pressure most strongly predicts future hypertension."
            },
            {
              "id": "B",
              "text": "Option A: Her reported intake of one or two alcoholic beverages on weekends does not suggest the greatest risk is alcohol use disorder."
            },
            {
              "id": "C",
              "text": "Option D: Obesity is inappropriate because her BMI is normal, and the vignette provides no evidence of excess caloric intake or progressive weight gain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hypercholesterolemia is inappropriate because a family history of hyperlipidemia is relevant, but her current elevated blood pressure most strongly predicts future hypertension."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obesity is inappropriate because her BMI is normal, and the vignette provides no evidence of excess caloric intake or progressive weight gain."
            },
            {
              "id": "B",
              "text": "Option A: Her reported intake of one or two alcoholic beverages on weekends does not suggest the greatest risk is alcohol use disorder."
            },
            {
              "id": "C",
              "text": "Option B: Hypercholesterolemia is inappropriate because a family history of hyperlipidemia is relevant, but her current elevated blood pressure most strongly predicts future hypertension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obesity is inappropriate because her BMI is normal, and the vignette provides no evidence of excess caloric intake or progressive weight gain."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Type 2 diabetes mellitus is inappropriate because she has a normal BMI and no stated diabetes risk factor that outweighs her elevated blood pressure."
            },
            {
              "id": "B",
              "text": "Option A: Her reported intake of one or two alcoholic beverages on weekends does not suggest the greatest risk is alcohol use disorder."
            },
            {
              "id": "C",
              "text": "Option B: Hypercholesterolemia is inappropriate because a family history of hyperlipidemia is relevant, but her current elevated blood pressure most strongly predicts future hypertension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Type 2 diabetes mellitus is inappropriate because she has a normal BMI and no stated diabetes risk factor that outweighs her elevated blood pressure."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i032-family-history-colorectal-screening",
      "expectedHashes": {
        "ranaze_step3_uat": "01182c4286f21dfaf4c5fc0bd279012e45c07403efed0a8491132eed1c2a5a08",
        "ranaze_step3_prd": "01182c4286f21dfaf4c5fc0bd279012e45c07403efed0a8491132eed1c2a5a08"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
            },
            {
              "id": "B",
              "text": "Option C: Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
            },
            {
              "id": "C",
              "text": "Option D: Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not a screening test for colorectal cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
            },
            {
              "id": "B",
              "text": "Option B: Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
            },
            {
              "id": "C",
              "text": "Option D: Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not a screening test for colorectal cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not a screening test for colorectal cancer."
            },
            {
              "id": "B",
              "text": "Option B: Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
            },
            {
              "id": "C",
              "text": "Option C: Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not a screening test for colorectal cancer."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT scan of the abdomen and pelvis is inappropriate because cT imaging is not a recommended colorectal cancer screening test in an asymptomatic patient."
            },
            {
              "id": "B",
              "text": "Option B: Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
            },
            {
              "id": "C",
              "text": "Option C: Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT scan of the abdomen and pelvis is inappropriate because cT imaging is not a recommended colorectal cancer screening test in an asymptomatic patient."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT colonography is a noncolonoscopy screening option, but it is not preferred for this increased-risk patient; any positive finding would also require colonoscopy."
            },
            {
              "id": "B",
              "text": "Option B: Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
            },
            {
              "id": "C",
              "text": "Option C: Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT colonography is a noncolonoscopy screening option, but it is not preferred for this increased-risk patient; any positive finding would also require colonoscopy."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Colon capsule endoscopy is not the recommended primary test for this strong family history and cannot biopsy or remove lesions. Complete optical colonoscopy is preferred."
            },
            {
              "id": "B",
              "text": "Option B: Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
            },
            {
              "id": "C",
              "text": "Option C: Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Colon capsule endoscopy is not the recommended primary test for this strong family history and cannot biopsy or remove lesions. Complete optical colonoscopy is preferred."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer screening until age 50 is inappropriate because screening should not be deferred. With two affected first-degree relatives, screening should begin at age 40 or 10 years before the youngest relative\u0027s diagnosis, whichever is earlier."
            },
            {
              "id": "B",
              "text": "Option B: Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
            },
            {
              "id": "C",
              "text": "Option C: Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer screening until age 50 is inappropriate because screening should not be deferred. With two affected first-degree relatives, screening should begin at age 40 or 10 years before the youngest relative\u0027s diagnosis, whichever is earlier."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Germline testing for Lynch syndrome instead of colorectal screening is inappropriate because genetic evaluation may be considered because of the family history, but it does not replace indicated colonoscopic screening. Her current need is direct examination of the entire colon."
            },
            {
              "id": "B",
              "text": "Option B: Annual fecal immunochemical testing alone is inappropriate because stool testing alone is less appropriate for a patient with this increased familial risk."
            },
            {
              "id": "C",
              "text": "Option C: Flexible sigmoidoscopy alone is inappropriate because flexible sigmoidoscopy does not evaluate the entire colon and is inadequate for this high-risk history."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Germline testing for Lynch syndrome instead of colorectal screening is inappropriate because genetic evaluation may be considered because of the family history, but it does not replace indicated colonoscopic screening. Her current need is direct examination of the entire colon."
        }
      }
    },
    {
      "externalId": "nbme5-s4-i033-poor-glycemic-control-retinopathy",
      "expectedHashes": {
        "ranaze_step3_uat": "008648d20909f9e9ffd4837d4f904226178e63ac3d163cb122d1831b784e74af",
        "ranaze_step3_prd": "008648d20909f9e9ffd4837d4f904226178e63ac3d163cb122d1831b784e74af"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute bacterial sepsis is inappropriate because poor glycemic control can increase infection susceptibility, but sepsis is not the characteristic major chronic complication predicted by hemoglobin A1c."
            },
            {
              "id": "B",
              "text": "Option C: Myocardial infarction within the next month is inappropriate because diabetes contributes to cardiovascular risk over time, but the key complication of severe chronic hyperglycemia in this young patient is microvascular disease."
            },
            {
              "id": "C",
              "text": "Option D: Ischemic stroke within the next month is inappropriate because stroke risk is increased by diabetes but is not the most characteristic consequence of this markedly elevated hemoglobin A1c."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute bacterial sepsis is inappropriate because poor glycemic control can increase infection susceptibility, but sepsis is not the characteristic major chronic complication predicted by hemoglobin A1c."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Myocardial infarction within the next month is inappropriate because diabetes contributes to cardiovascular risk over time, but the key complication of severe chronic hyperglycemia in this young patient is microvascular disease."
            },
            {
              "id": "B",
              "text": "Option B: Acute bacterial sepsis is inappropriate because poor glycemic control can increase infection susceptibility, but sepsis is not the characteristic major chronic complication predicted by hemoglobin A1c."
            },
            {
              "id": "C",
              "text": "Option D: Ischemic stroke within the next month is inappropriate because stroke risk is increased by diabetes but is not the most characteristic consequence of this markedly elevated hemoglobin A1c."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Myocardial infarction within the next month is inappropriate because diabetes contributes to cardiovascular risk over time, but the key complication of severe chronic hyperglycemia in this young patient is microvascular disease."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ischemic stroke within the next month is inappropriate because stroke risk is increased by diabetes but is not the most characteristic consequence of this markedly elevated hemoglobin A1c."
            },
            {
              "id": "B",
              "text": "Option B: Acute bacterial sepsis is inappropriate because poor glycemic control can increase infection susceptibility, but sepsis is not the characteristic major chronic complication predicted by hemoglobin A1c."
            },
            {
              "id": "C",
              "text": "Option C: Myocardial infarction within the next month is inappropriate because diabetes contributes to cardiovascular risk over time, but the key complication of severe chronic hyperglycemia in this young patient is microvascular disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ischemic stroke within the next month is inappropriate because stroke risk is increased by diabetes but is not the most characteristic consequence of this markedly elevated hemoglobin A1c."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Peptic ulcer disease is not a typical complication of chronic hyperglycemia."
            },
            {
              "id": "B",
              "text": "Option B: Acute bacterial sepsis is inappropriate because poor glycemic control can increase infection susceptibility, but sepsis is not the characteristic major chronic complication predicted by hemoglobin A1c."
            },
            {
              "id": "C",
              "text": "Option C: Myocardial infarction within the next month is inappropriate because diabetes contributes to cardiovascular risk over time, but the key complication of severe chronic hyperglycemia in this young patient is microvascular disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Peptic ulcer disease is not a typical complication of chronic hyperglycemia."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i001-acute-dystonic-reaction",
      "expectedHashes": {
        "ranaze_step3_uat": "64c9f27194f5bdaafe1307baab67faff39b50eb7e54af8f6d7525046cdb64b2c",
        "ranaze_step3_prd": "64c9f27194f5bdaafe1307baab67faff39b50eb7e54af8f6d7525046cdb64b2c"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "B",
              "text": "Option C: Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            },
            {
              "id": "C",
              "text": "Option D: Lorazepam can be adjunctive in refractory cases but is not first-line when an anticholinergic medication is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acetaminophen does not reverse dopamine antagonist-induced dystonia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            },
            {
              "id": "B",
              "text": "Option A: Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "C",
              "text": "Option D: Lorazepam can be adjunctive in refractory cases but is not first-line when an anticholinergic medication is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lorazepam can be adjunctive in refractory cases but is not first-line when an anticholinergic medication is available."
            },
            {
              "id": "B",
              "text": "Option A: Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "C",
              "text": "Option C: Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lorazepam can be adjunctive in refractory cases but is not first-line when an anticholinergic medication is available."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No medication and outpatient observation is inappropriate because observation alone is inappropriate because the patient has distressing acute dystonia requiring prompt treatment."
            },
            {
              "id": "B",
              "text": "Option A: Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "C",
              "text": "Option C: Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No medication and outpatient observation is inappropriate because observation alone is inappropriate because the patient has distressing acute dystonia requiring prompt treatment."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cyproheptadine is a serotonin antagonist used for serotonin syndrome. The trigger here is increased dopamine blockade by risperidone, without hyperthermia, autonomic instability, or serotonergic exposure."
            },
            {
              "id": "B",
              "text": "Option A: Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "C",
              "text": "Option C: Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cyproheptadine is a serotonin antagonist used for serotonin syndrome. The trigger here is increased dopamine blockade by risperidone, without hyperthermia, autonomic instability, or serotonergic exposure."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Propranolol is commonly used for antipsychotic-induced akathisia, which presents as subjective restlessness and inability to remain still. It does not rapidly reverse this patient\u0027s sustained jaw, neck, and ocular dystonia."
            },
            {
              "id": "B",
              "text": "Option A: Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "C",
              "text": "Option C: Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Propranolol is commonly used for antipsychotic-induced akathisia, which presents as subjective restlessness and inability to remain still. It does not rapidly reverse this patient\u0027s sustained jaw, neck, and ocular dystonia."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Valbenazine, a VMAT2 inhibitor, treats tardive dyskinesia associated with chronic dopamine-receptor blockade. This reaction began two hours after a dose increase and consists of sustained painful posturing, indicating acute dystonia."
            },
            {
              "id": "B",
              "text": "Option A: Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "C",
              "text": "Option C: Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Valbenazine, a VMAT2 inhibitor, treats tardive dyskinesia associated with chronic dopamine-receptor blockade. This reaction began two hours after a dose increase and consists of sustained painful posturing, indicating acute dystonia."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Botulinum toxin injection into the neck muscles is inappropriate because botulinum toxin is appropriate for selected chronic focal or segmental dystonias, not the immediate treatment of a generalized medication-induced acute dystonic reaction."
            },
            {
              "id": "B",
              "text": "Option A: Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "C",
              "text": "Option C: Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Botulinum toxin injection into the neck muscles is inappropriate because botulinum toxin is appropriate for selected chronic focal or segmental dystonias, not the immediate treatment of a generalized medication-induced acute dystonic reaction."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dantrolene may be used for persistent rigidity and hyperthermia in neuroleptic malignant syndrome, but this patient has an acute dystonic reaction: torticollis, jaw spasm, and an oculogyric crisis beginning two hours after a risperidone dose increase, with preserved alertness and normal vital signs. Acute dystonia is treated promptly with parenteral diphenhydramine or benztropine."
            },
            {
              "id": "B",
              "text": "Option A: Acetaminophen does not reverse dopamine antagonist-induced dystonia."
            },
            {
              "id": "C",
              "text": "Option C: Levetiracetam is not indicated because the patient remains alert and has medication-induced sustained muscle contractions rather than a seizure disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dantrolene may be used for persistent rigidity and hyperthermia in neuroleptic malignant syndrome, but this patient has an acute dystonic reaction: torticollis, jaw spasm, and an oculogyric crisis beginning two hours after a risperidone dose increase, with preserved alertness and normal vital signs. Acute dystonia is treated promptly with parenteral diphenhydramine or benztropine."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i002-prostaglandin-for-transposition",
      "expectedHashes": {
        "ranaze_step3_uat": "0eb26120b41aecb608ca244ba83b88f01fd5fde262560130f0e0871080a59daa",
        "ranaze_step3_prd": "0eb26120b41aecb608ca244ba83b88f01fd5fde262560130f0e0871080a59daa"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
            },
            {
              "id": "B",
              "text": "Option C: Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
            },
            {
              "id": "C",
              "text": "Option D: Perform endotracheal intubation for primary respiratory failure is inappropriate because intubation does not correct the circulatory mixing defect causing cyanosis that fails to improve with 100% oxygen."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
            },
            {
              "id": "C",
              "text": "Option D: Perform endotracheal intubation for primary respiratory failure is inappropriate because intubation does not correct the circulatory mixing defect causing cyanosis that fails to improve with 100% oxygen."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform endotracheal intubation for primary respiratory failure is inappropriate because intubation does not correct the circulatory mixing defect causing cyanosis that fails to improve with 100% oxygen."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
            },
            {
              "id": "C",
              "text": "Option C: Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform endotracheal intubation for primary respiratory failure is inappropriate because intubation does not correct the circulatory mixing defect causing cyanosis that fails to improve with 100% oxygen."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfuse packed red blood cells is inappropriate because the hematocrit is normal, so anemia is not causing the severe cyanosis."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
            },
            {
              "id": "C",
              "text": "Option C: Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfuse packed red blood cells is inappropriate because the hematocrit is normal, so anemia is not causing the severe cyanosis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain transthoracic echocardiography before initiating treatment is inappropriate because echocardiography is needed to define the cardiac anatomy, but profound oxygen-refractory neonatal cyanosis should trigger immediate prostaglandin E1 treatment for a suspected ductal-dependent lesion rather than delaying treatment for imaging."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
            },
            {
              "id": "C",
              "text": "Option C: Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain transthoracic echocardiography before initiating treatment is inappropriate because echocardiography is needed to define the cardiac anatomy, but profound oxygen-refractory neonatal cyanosis should trigger immediate prostaglandin E1 treatment for a suspected ductal-dependent lesion rather than delaying treatment for imaging."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous furosemide is inappropriate because furosemide is used for volume overload or pulmonary edema. This infant has clear lungs, normal capillary refill, and no findings of congestion; diuresis would not improve intracardiac mixing."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
            },
            {
              "id": "C",
              "text": "Option C: Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous furosemide is inappropriate because furosemide is used for volume overload or pulmonary edema. This infant has clear lungs, normal capillary refill, and no findings of congestion; diuresis would not improve intracardiac mixing."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly to an arterial switch operation is inappropriate because an arterial switch operation is definitive treatment for d-transposition, generally performed early in life after diagnosis and stabilization. It is not the first bedside intervention for an unstable, severely cyanotic newborn whose ductal patency must be restored immediately."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
            },
            {
              "id": "C",
              "text": "Option C: Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly to an arterial switch operation is inappropriate because an arterial switch operation is definitive treatment for d-transposition, generally performed early in life after diagnosis and stabilization. It is not the first bedside intervention for an unstable, severely cyanotic newborn whose ductal patency must be restored immediately."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer indomethacin to close the ductus arteriosus is inappropriate because indomethacin promotes ductal closure and would worsen a suspected ductal-dependent lesion. This infant instead requires maintenance or reopening of the ductus with prostaglandin E1."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous ampicillin and gentamicin is inappropriate because empiric antibiotics may be appropriate when sepsis is suspected but do not address profound oxygen-refractory cyanosis with a benign pulmonary examination."
            },
            {
              "id": "C",
              "text": "Option C: Give a rapid intravenous normal saline bolus is inappropriate because the infant has normal capillary refill and no evidence of hypovolemia requiring fluid resuscitation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer indomethacin to close the ductus arteriosus is inappropriate because indomethacin promotes ductal closure and would worsen a suspected ductal-dependent lesion. This infant instead requires maintenance or reopening of the ductus with prostaglandin E1."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i004-fulminant-c-difficile-colitis",
      "expectedHashes": {
        "ranaze_step3_uat": "79b4afef25e376d69bea51d02858b28b2fc95822c7ce5a3187b57bb3052991c4",
        "ranaze_step3_prd": "79b4afef25e376d69bea51d02858b28b2fc95822c7ce5a3187b57bb3052991c4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "B",
              "text": "Option C: Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            },
            {
              "id": "C",
              "text": "Option D: Continue antibiotics without additional intervention is inappropriate because antibiotics alone are insufficient management when shock, severe leukocytosis, and toxic megacolon are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            },
            {
              "id": "B",
              "text": "Option B: Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "C",
              "text": "Option D: Continue antibiotics without additional intervention is inappropriate because antibiotics alone are insufficient management when shock, severe leukocytosis, and toxic megacolon are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue antibiotics without additional intervention is inappropriate because antibiotics alone are insufficient management when shock, severe leukocytosis, and toxic megacolon are present."
            },
            {
              "id": "B",
              "text": "Option B: Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "C",
              "text": "Option C: Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue antibiotics without additional intervention is inappropriate because antibiotics alone are insufficient management when shock, severe leukocytosis, and toxic megacolon are present."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat stool toxin testing tomorrow is inappropriate because repeat toxin testing delays needed escalation and does not alter management of confirmed fulminant infection."
            },
            {
              "id": "B",
              "text": "Option B: Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "C",
              "text": "Option C: Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat stool toxin testing tomorrow is inappropriate because repeat toxin testing delays needed escalation and does not alter management of confirmed fulminant infection."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Replace oral vancomycin with intravenous vancomycin is inappropriate because intravenous vancomycin does not provide the required intraluminal colonic therapy. Fulminant C difficile infection is treated with high-dose vancomycin orally or by nasogastric tube plus intravenous metronidazole; rectal vancomycin may be added if ileus limits delivery."
            },
            {
              "id": "B",
              "text": "Option B: Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "C",
              "text": "Option C: Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Replace oral vancomycin with intravenous vancomycin is inappropriate because intravenous vancomycin does not provide the required intraluminal colonic therapy. Fulminant C difficile infection is treated with high-dose vancomycin orally or by nasogastric tube plus intravenous metronidazole; rectal vancomycin may be added if ileus limits delivery."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Replace oral vancomycin with oral fidaxomicin is inappropriate because fidaxomicin is preferred for many nonfulminant initial episodes, but trials supporting it excluded fulminant disease. Current IDSA/SHEA guidance retains high-dose enteral vancomycin for fulminant infection."
            },
            {
              "id": "B",
              "text": "Option B: Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "C",
              "text": "Option C: Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Replace oral vancomycin with oral fidaxomicin is inappropriate because fidaxomicin is preferred for many nonfulminant initial episodes, but trials supporting it excluded fulminant disease. Current IDSA/SHEA guidance retains high-dose enteral vancomycin for fulminant infection."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer loperamide to control the diarrhea is inappropriate because an antimotility agent can worsen toxin retention and colonic dilation and is especially inappropriate in a patient who already has toxic megacolon."
            },
            {
              "id": "B",
              "text": "Option B: Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "C",
              "text": "Option C: Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer loperamide to control the diarrhea is inappropriate because an antimotility agent can worsen toxin retention and colonic dilation and is especially inappropriate in a patient who already has toxic megacolon."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer bezlotoxumab as the principal acute intervention is inappropriate because bezlotoxumab is an adjunct intended to reduce future recurrence in selected patients receiving antibacterial treatment. It does not treat shock, toxic megacolon, or the need for urgent surgical assessment."
            },
            {
              "id": "B",
              "text": "Option B: Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "C",
              "text": "Option C: Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer bezlotoxumab as the principal acute intervention is inappropriate because bezlotoxumab is an adjunct intended to reduce future recurrence in selected patients receiving antibacterial treatment. It does not treat shock, toxic megacolon, or the need for urgent surgical assessment."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin high-dose intravenous glucocorticoids is inappropriate because glucocorticoids are used for inflammatory colitis, not toxin-confirmed C difficile colitis. Immunosuppression would not address this fulminant infection and could impede host response."
            },
            {
              "id": "B",
              "text": "Option B: Perform decompressive colonoscopy is inappropriate because colonoscopy can perforate a severely inflamed, dilated colon and does not address fulminant C difficile colitis."
            },
            {
              "id": "C",
              "text": "Option C: Place a tube cecostomy is inappropriate because tube cecostomy is not standard management for toxic megacolon caused by fulminant C difficile infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin high-dose intravenous glucocorticoids is inappropriate because glucocorticoids are used for inflammatory colitis, not toxin-confirmed C difficile colitis. Immunosuppression would not address this fulminant infection and could impede host response."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i005-calcium-lactose-intolerance",
      "expectedHashes": {
        "ranaze_step3_uat": "ab385eb7ecb87b71a5ce1ac90718f133ae170f19dfd10fec764ff7b1e5971da1",
        "ranaze_step3_prd": "ab385eb7ecb87b71a5ce1ac90718f133ae170f19dfd10fec764ff7b1e5971da1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Raw spinach is inappropriate because spinach contains calcium, but oxalate substantially reduces calcium absorption."
            },
            {
              "id": "B",
              "text": "Option C: Kelp supplements is inappropriate because kelp is not a reliable dietary calcium source and may expose patients to excessive iodine."
            },
            {
              "id": "C",
              "text": "Option D: Sweetened condensed milk contains lactose and added sugar, making it a poor choice for someone who develops symptoms with milk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Raw spinach is inappropriate because spinach contains calcium, but oxalate substantially reduces calcium absorption."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Kelp supplements is inappropriate because kelp is not a reliable dietary calcium source and may expose patients to excessive iodine."
            },
            {
              "id": "B",
              "text": "Option B: Raw spinach is inappropriate because spinach contains calcium, but oxalate substantially reduces calcium absorption."
            },
            {
              "id": "C",
              "text": "Option D: Sweetened condensed milk contains lactose and added sugar, making it a poor choice for someone who develops symptoms with milk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Kelp supplements is inappropriate because kelp is not a reliable dietary calcium source and may expose patients to excessive iodine."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sweetened condensed milk contains lactose and added sugar, making it a poor choice for someone who develops symptoms with milk."
            },
            {
              "id": "B",
              "text": "Option B: Raw spinach is inappropriate because spinach contains calcium, but oxalate substantially reduces calcium absorption."
            },
            {
              "id": "C",
              "text": "Option C: Kelp supplements is inappropriate because kelp is not a reliable dietary calcium source and may expose patients to excessive iodine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sweetened condensed milk contains lactose and added sugar, making it a poor choice for someone who develops symptoms with milk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Spirulina powder is inappropriate because spirulina is not a dependable source of bioavailable calcium."
            },
            {
              "id": "B",
              "text": "Option B: Raw spinach is inappropriate because spinach contains calcium, but oxalate substantially reduces calcium absorption."
            },
            {
              "id": "C",
              "text": "Option C: Kelp supplements is inappropriate because kelp is not a reliable dietary calcium source and may expose patients to excessive iodine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Spirulina powder is inappropriate because spirulina is not a dependable source of bioavailable calcium."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unfortified almond beverages are not dependable calcium sources; plant beverages provide substantial calcium only when calcium has been added and the product label confirms it."
            },
            {
              "id": "B",
              "text": "Option B: Raw spinach is inappropriate because spinach contains calcium, but oxalate substantially reduces calcium absorption."
            },
            {
              "id": "C",
              "text": "Option C: Kelp supplements is inappropriate because kelp is not a reliable dietary calcium source and may expose patients to excessive iodine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unfortified almond beverages are not dependable calcium sources; plant beverages provide substantial calcium only when calcium has been added and the product label confirms it."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Canned boneless salmon is inappropriate because the calcium in canned salmon is primarily supplied by edible bones. Boneless salmon does not reliably provide enough calcium to close this patient\u0027s dietary deficit."
            },
            {
              "id": "B",
              "text": "Option B: Raw spinach is inappropriate because spinach contains calcium, but oxalate substantially reduces calcium absorption."
            },
            {
              "id": "C",
              "text": "Option C: Kelp supplements is inappropriate because kelp is not a reliable dietary calcium source and may expose patients to excessive iodine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Canned boneless salmon is inappropriate because the calcium in canned salmon is primarily supplied by edible bones. Boneless salmon does not reliably provide enough calcium to close this patient\u0027s dietary deficit."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unfortified wheat-bran cereal is inappropriate because unfortified cereal is not a concentrated calcium source, and wheat bran contains phytate, which can reduce calcium absorption."
            },
            {
              "id": "B",
              "text": "Option B: Raw spinach is inappropriate because spinach contains calcium, but oxalate substantially reduces calcium absorption."
            },
            {
              "id": "C",
              "text": "Option C: Kelp supplements is inappropriate because kelp is not a reliable dietary calcium source and may expose patients to excessive iodine."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unfortified wheat-bran cereal is inappropriate because unfortified cereal is not a concentrated calcium source, and wheat bran contains phytate, which can reduce calcium absorption."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i007-panic-disorder-ssri",
      "expectedHashes": {
        "ranaze_step3_uat": "6f408bed6876a1a687219a9308531562060860a23dd0ec1b5fea944ae0207ae3",
        "ranaze_step3_prd": "6f408bed6876a1a687219a9308531562060860a23dd0ec1b5fea944ae0207ae3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
            },
            {
              "id": "B",
              "text": "Option C: Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
            },
            {
              "id": "C",
              "text": "Option D: Propranolol may reduce performance-related autonomic symptoms but does not treat recurrent unexpected panic attacks."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
            },
            {
              "id": "B",
              "text": "Option B: Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
            },
            {
              "id": "C",
              "text": "Option D: Propranolol may reduce performance-related autonomic symptoms but does not treat recurrent unexpected panic attacks."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Propranolol may reduce performance-related autonomic symptoms but does not treat recurrent unexpected panic attacks."
            },
            {
              "id": "B",
              "text": "Option B: Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
            },
            {
              "id": "C",
              "text": "Option C: Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Propranolol may reduce performance-related autonomic symptoms but does not treat recurrent unexpected panic attacks."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Haloperidol is used for psychosis or severe agitation, not panic disorder maintenance treatment."
            },
            {
              "id": "B",
              "text": "Option B: Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
            },
            {
              "id": "C",
              "text": "Option C: Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Haloperidol is used for psychosis or severe agitation, not panic disorder maintenance treatment."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Buspirone is used for generalized anxiety disorder but does not have established efficacy as maintenance treatment for recurrent unexpected panic attacks."
            },
            {
              "id": "B",
              "text": "Option B: Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
            },
            {
              "id": "C",
              "text": "Option C: Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Buspirone is used for generalized anxiety disorder but does not have established efficacy as maintenance treatment for recurrent unexpected panic attacks."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hydroxyzine is a sedating antihistamine and is not recommended for panic disorder maintenance treatment."
            },
            {
              "id": "B",
              "text": "Option B: Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
            },
            {
              "id": "C",
              "text": "Option C: Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hydroxyzine is a sedating antihistamine and is not recommended for panic disorder maintenance treatment."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bupropion is not an evidence-based first-line treatment for panic disorder and can be activating; an SSRI or an evidence-supported SNRI is preferred."
            },
            {
              "id": "B",
              "text": "Option B: Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
            },
            {
              "id": "C",
              "text": "Option C: Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bupropion is not an evidence-based first-line treatment for panic disorder and can be activating; an SSRI or an evidence-supported SNRI is preferred."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Although duloxetine is an SNRI used for generalized anxiety disorder, the evidence-supported and licensed SNRI for panic disorder is venlafaxine; sertraline is the appropriate first-line option presented here."
            },
            {
              "id": "B",
              "text": "Option B: Alprazolam can rapidly reduce anxiety but is not preferred as long-term monotherapy because of dependence and withdrawal risks."
            },
            {
              "id": "C",
              "text": "Option C: Olanzapine is an antipsychotic used for psychotic and bipolar disorders, neither of which is present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Although duloxetine is an SNRI used for generalized anxiety disorder, the evidence-supported and licensed SNRI for panic disorder is venlafaxine; sertraline is the appropriate first-line option presented here."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i008-silicosis-tuberculosis",
      "expectedHashes": {
        "ranaze_step3_uat": "dcc2d383764e7405108b6ce62d447381ae90949145333e4155bdb752c06e3238",
        "ranaze_step3_prd": "dcc2d383764e7405108b6ce62d447381ae90949145333e4155bdb752c06e3238"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspergillosis is more classically associated with preexisting lung cavities, neutropenia, or severe immunosuppression."
            },
            {
              "id": "B",
              "text": "Option C: Mucormycosis typically occurs with severe immunocompromise, especially diabetic ketoacidosis or profound neutropenia."
            },
            {
              "id": "C",
              "text": "Option D: Nocardiosis is most associated with impaired cell-mediated immunity, such as chronic glucocorticoid use or transplantation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspergillosis is more classically associated with preexisting lung cavities, neutropenia, or severe immunosuppression."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mucormycosis typically occurs with severe immunocompromise, especially diabetic ketoacidosis or profound neutropenia."
            },
            {
              "id": "B",
              "text": "Option B: Aspergillosis is more classically associated with preexisting lung cavities, neutropenia, or severe immunosuppression."
            },
            {
              "id": "C",
              "text": "Option D: Nocardiosis is most associated with impaired cell-mediated immunity, such as chronic glucocorticoid use or transplantation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mucormycosis typically occurs with severe immunocompromise, especially diabetic ketoacidosis or profound neutropenia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nocardiosis is most associated with impaired cell-mediated immunity, such as chronic glucocorticoid use or transplantation."
            },
            {
              "id": "B",
              "text": "Option B: Aspergillosis is more classically associated with preexisting lung cavities, neutropenia, or severe immunosuppression."
            },
            {
              "id": "C",
              "text": "Option C: Mucormycosis typically occurs with severe immunocompromise, especially diabetic ketoacidosis or profound neutropenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nocardiosis is most associated with impaired cell-mediated immunity, such as chronic glucocorticoid use or transplantation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Actinomycosis is associated with aspiration and poor dentition rather than silica exposure."
            },
            {
              "id": "B",
              "text": "Option B: Aspergillosis is more classically associated with preexisting lung cavities, neutropenia, or severe immunosuppression."
            },
            {
              "id": "C",
              "text": "Option C: Mucormycosis typically occurs with severe immunocompromise, especially diabetic ketoacidosis or profound neutropenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Actinomycosis is associated with aspiration and poor dentition rather than silica exposure."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Older age, smoking history, and chronic lung disease can increase the general risk of pneumococcal disease, but pneumococcal pneumonia is not the signature infection of silica-induced macrophage dysfunction."
            },
            {
              "id": "B",
              "text": "Option B: Aspergillosis is more classically associated with preexisting lung cavities, neutropenia, or severe immunosuppression."
            },
            {
              "id": "C",
              "text": "Option C: Mucormycosis typically occurs with severe immunocompromise, especially diabetic ketoacidosis or profound neutropenia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Older age, smoking history, and chronic lung disease can increase the general risk of pneumococcal disease, but pneumococcal pneumonia is not the signature infection of silica-induced macrophage dysfunction."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i010-cerumen-irrigation",
      "expectedHashes": {
        "ranaze_step3_uat": "8091bbf6a99c535836ea3e5754b3128e35e8c50e876903e8b2c29b57692e0d5f",
        "ranaze_step3_prd": "8091bbf6a99c535836ea3e5754b3128e35e8c50e876903e8b2c29b57692e0d5f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a CT scan of the head is inappropriate because neuroimaging is not indicated for an apparent bilateral conductive cause of hearing loss."
            },
            {
              "id": "B",
              "text": "Option C: Refer immediately for otolaryngology evaluation is inappropriate because specialist referral is unnecessary before attempting routine cerumen removal in an uncomplicated case."
            },
            {
              "id": "C",
              "text": "Option D: Provide reassurance without intervention is inappropriate because the hearing difficulty is symptomatic and has a reversible cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a CT scan of the head is inappropriate because neuroimaging is not indicated for an apparent bilateral conductive cause of hearing loss."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer immediately for otolaryngology evaluation is inappropriate because specialist referral is unnecessary before attempting routine cerumen removal in an uncomplicated case."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a CT scan of the head is inappropriate because neuroimaging is not indicated for an apparent bilateral conductive cause of hearing loss."
            },
            {
              "id": "C",
              "text": "Option D: Provide reassurance without intervention is inappropriate because the hearing difficulty is symptomatic and has a reversible cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer immediately for otolaryngology evaluation is inappropriate because specialist referral is unnecessary before attempting routine cerumen removal in an uncomplicated case."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide reassurance without intervention is inappropriate because the hearing difficulty is symptomatic and has a reversible cause."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a CT scan of the head is inappropriate because neuroimaging is not indicated for an apparent bilateral conductive cause of hearing loss."
            },
            {
              "id": "C",
              "text": "Option C: Refer immediately for otolaryngology evaluation is inappropriate because specialist referral is unnecessary before attempting routine cerumen removal in an uncomplicated case."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide reassurance without intervention is inappropriate because the hearing difficulty is symptomatic and has a reversible cause."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend ceruminolytic drops alone and reassess only if symptoms persist is inappropriate because ceruminolytics can be used, but complete symptomatic bilateral obstruction can be treated directly with irrigation."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a CT scan of the head is inappropriate because neuroimaging is not indicated for an apparent bilateral conductive cause of hearing loss."
            },
            {
              "id": "C",
              "text": "Option C: Refer immediately for otolaryngology evaluation is inappropriate because specialist referral is unnecessary before attempting routine cerumen removal in an uncomplicated case."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend ceruminolytic drops alone and reassess only if symptoms persist is inappropriate because ceruminolytics can be used, but complete symptomatic bilateral obstruction can be treated directly with irrigation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order formal audiometry before attempting cerumen removal is inappropriate because audiometry may be appropriate if hearing loss persists after treatment, but testing through completely occluded canals would confirm a predictable conductive deficit without addressing its visible reversible cause."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a CT scan of the head is inappropriate because neuroimaging is not indicated for an apparent bilateral conductive cause of hearing loss."
            },
            {
              "id": "C",
              "text": "Option C: Refer immediately for otolaryngology evaluation is inappropriate because specialist referral is unnecessary before attempting routine cerumen removal in an uncomplicated case."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order formal audiometry before attempting cerumen removal is inappropriate because audiometry may be appropriate if hearing loss persists after treatment, but testing through completely occluded canals would confirm a predictable conductive deficit without addressing its visible reversible cause."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fit bilateral hearing aids without first removing the cerumen is inappropriate because hearing aids should not be fitted before correcting complete cerumen obstruction. Cerumen removal may resolve the hearing difficulty and is also necessary for an adequate ear examination."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a CT scan of the head is inappropriate because neuroimaging is not indicated for an apparent bilateral conductive cause of hearing loss."
            },
            {
              "id": "C",
              "text": "Option C: Refer immediately for otolaryngology evaluation is inappropriate because specialist referral is unnecessary before attempting routine cerumen removal in an uncomplicated case."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fit bilateral hearing aids without first removing the cerumen is inappropriate because hearing aids should not be fitted before correcting complete cerumen obstruction. Cerumen removal may resolve the hearing difficulty and is also necessary for an adequate ear examination."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with oral glucocorticoids for presumed sudden sensorineural hearing loss is inappropriate because sudden sensorineural hearing loss is treated urgently with glucocorticoids, but her loss is progressive and the tuning-fork result indicates conductive rather than sensorineural dysfunction."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a CT scan of the head is inappropriate because neuroimaging is not indicated for an apparent bilateral conductive cause of hearing loss."
            },
            {
              "id": "C",
              "text": "Option C: Refer immediately for otolaryngology evaluation is inappropriate because specialist referral is unnecessary before attempting routine cerumen removal in an uncomplicated case."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with oral glucocorticoids for presumed sudden sensorineural hearing loss is inappropriate because sudden sensorineural hearing loss is treated urgently with glucocorticoids, but her loss is progressive and the tuning-fork result indicates conductive rather than sensorineural dysfunction."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i011-exertional-symptoms-severe-aortic-stenosis",
      "expectedHashes": {
        "ranaze_step3_uat": "8d37787af7c232825729f5b8824beb399d4b25909bbaf0b6c77acd4f1b24377d",
        "ranaze_step3_prd": "8d37787af7c232825729f5b8824beb399d4b25909bbaf0b6c77acd4f1b24377d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Metoprolol therapy alone is inappropriate because metoprolol may be useful for selected coexisting conditions but does not correct severe valvular obstruction and is not definitive therapy."
            },
            {
              "id": "B",
              "text": "Option C: Balloon aortic valvuloplasty as definitive therapy is inappropriate because balloon aortic valvuloplasty has limited durability in adults and is generally used as a bridge to valve replacement or for palliation when replacement is not feasible."
            },
            {
              "id": "C",
              "text": "Option D: Supervised exercise training alone is inappropriate because exercise training alone does not treat symptomatic severe aortic stenosis and may worsen exertional symptoms before valve intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Metoprolol therapy alone is inappropriate because metoprolol may be useful for selected coexisting conditions but does not correct severe valvular obstruction and is not definitive therapy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Balloon aortic valvuloplasty as definitive therapy is inappropriate because balloon aortic valvuloplasty has limited durability in adults and is generally used as a bridge to valve replacement or for palliation when replacement is not feasible."
            },
            {
              "id": "B",
              "text": "Option B: Metoprolol therapy alone is inappropriate because metoprolol may be useful for selected coexisting conditions but does not correct severe valvular obstruction and is not definitive therapy."
            },
            {
              "id": "C",
              "text": "Option D: Supervised exercise training alone is inappropriate because exercise training alone does not treat symptomatic severe aortic stenosis and may worsen exertional symptoms before valve intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Balloon aortic valvuloplasty as definitive therapy is inappropriate because balloon aortic valvuloplasty has limited durability in adults and is generally used as a bridge to valve replacement or for palliation when replacement is not feasible."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Supervised exercise training alone is inappropriate because exercise training alone does not treat symptomatic severe aortic stenosis and may worsen exertional symptoms before valve intervention."
            },
            {
              "id": "B",
              "text": "Option B: Metoprolol therapy alone is inappropriate because metoprolol may be useful for selected coexisting conditions but does not correct severe valvular obstruction and is not definitive therapy."
            },
            {
              "id": "C",
              "text": "Option C: Balloon aortic valvuloplasty as definitive therapy is inappropriate because balloon aortic valvuloplasty has limited durability in adults and is generally used as a bridge to valve replacement or for palliation when replacement is not feasible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Supervised exercise training alone is inappropriate because exercise training alone does not treat symptomatic severe aortic stenosis and may worsen exertional symptoms before valve intervention."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long-acting nitrate therapy alone is inappropriate because long-acting nitrates do not relieve fixed aortic valve obstruction and can precipitate hypotension in patients with severe aortic stenosis."
            },
            {
              "id": "B",
              "text": "Option B: Metoprolol therapy alone is inappropriate because metoprolol may be useful for selected coexisting conditions but does not correct severe valvular obstruction and is not definitive therapy."
            },
            {
              "id": "C",
              "text": "Option C: Balloon aortic valvuloplasty as definitive therapy is inappropriate because balloon aortic valvuloplasty has limited durability in adults and is generally used as a bridge to valve replacement or for palliation when replacement is not feasible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long-acting nitrate therapy alone is inappropriate because long-acting nitrates do not relieve fixed aortic valve obstruction and can precipitate hypotension in patients with severe aortic stenosis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serial echocardiography with watchful waiting is inappropriate because watchful waiting is appropriate for selected asymptomatic patients, but this patient has exertional dyspnea, angina, and lightheadedness with high-gradient severe aortic stenosis. Symptomatic severe disease is an indication for aortic valve replacement."
            },
            {
              "id": "B",
              "text": "Option B: Metoprolol therapy alone is inappropriate because metoprolol may be useful for selected coexisting conditions but does not correct severe valvular obstruction and is not definitive therapy."
            },
            {
              "id": "C",
              "text": "Option C: Balloon aortic valvuloplasty as definitive therapy is inappropriate because balloon aortic valvuloplasty has limited durability in adults and is generally used as a bridge to valve replacement or for palliation when replacement is not feasible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serial echocardiography with watchful waiting is inappropriate because watchful waiting is appropriate for selected asymptomatic patients, but this patient has exertional dyspnea, angina, and lightheadedness with high-gradient severe aortic stenosis. Symptomatic severe disease is an indication for aortic valve replacement."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exercise treadmill testing before deciding on intervention is inappropriate because exercise testing can help reveal symptoms in apparently asymptomatic severe aortic stenosis. This patient already has clear exertional symptoms and a mean gradient of 44 mm Hg, so testing would not replace or appropriately delay valve intervention."
            },
            {
              "id": "B",
              "text": "Option B: Metoprolol therapy alone is inappropriate because metoprolol may be useful for selected coexisting conditions but does not correct severe valvular obstruction and is not definitive therapy."
            },
            {
              "id": "C",
              "text": "Option C: Balloon aortic valvuloplasty as definitive therapy is inappropriate because balloon aortic valvuloplasty has limited durability in adults and is generally used as a bridge to valve replacement or for palliation when replacement is not feasible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exercise treadmill testing before deciding on intervention is inappropriate because exercise testing can help reveal symptoms in apparently asymptomatic severe aortic stenosis. This patient already has clear exertional symptoms and a mean gradient of 44 mm Hg, so testing would not replace or appropriately delay valve intervention."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Coronary angiography and revascularization alone is inappropriate because coronary evaluation may be part of preprocedural planning, and concomitant coronary disease may require treatment, but revascularization alone cannot relieve the fixed obstruction across the severely stenotic aortic valve."
            },
            {
              "id": "B",
              "text": "Option B: Metoprolol therapy alone is inappropriate because metoprolol may be useful for selected coexisting conditions but does not correct severe valvular obstruction and is not definitive therapy."
            },
            {
              "id": "C",
              "text": "Option C: Balloon aortic valvuloplasty as definitive therapy is inappropriate because balloon aortic valvuloplasty has limited durability in adults and is generally used as a bridge to valve replacement or for palliation when replacement is not feasible."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Coronary angiography and revascularization alone is inappropriate because coronary evaluation may be part of preprocedural planning, and concomitant coronary disease may require treatment, but revascularization alone cannot relieve the fixed obstruction across the severely stenotic aortic valve."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i012-urge-incontinence-bladder-training",
      "expectedHashes": {
        "ranaze_step3_uat": "d691793359530f47420df8556ced42df40ec990d1ebf9f6af6d4a628e68dbee8",
        "ranaze_step3_prd": "d691793359530f47420df8556ced42df40ec990d1ebf9f6af6d4a628e68dbee8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Abdominal retropubic urethropexy is inappropriate because retropubic urethropexy treats stress incontinence, not urgency-predominant leakage."
            },
            {
              "id": "B",
              "text": "Option C: Periurethral bulking-agent injections is inappropriate because periurethral bulking procedures are used for stress incontinence due to outlet insufficiency."
            },
            {
              "id": "C",
              "text": "Option D: Psychiatric evaluation as the initial intervention is inappropriate because her low mood appears secondary to the functional impact of incontinence; the incontinence should be addressed first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Abdominal retropubic urethropexy is inappropriate because retropubic urethropexy treats stress incontinence, not urgency-predominant leakage."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Periurethral bulking-agent injections is inappropriate because periurethral bulking procedures are used for stress incontinence due to outlet insufficiency."
            },
            {
              "id": "B",
              "text": "Option B: Abdominal retropubic urethropexy is inappropriate because retropubic urethropexy treats stress incontinence, not urgency-predominant leakage."
            },
            {
              "id": "C",
              "text": "Option D: Psychiatric evaluation as the initial intervention is inappropriate because her low mood appears secondary to the functional impact of incontinence; the incontinence should be addressed first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Periurethral bulking-agent injections is inappropriate because periurethral bulking procedures are used for stress incontinence due to outlet insufficiency."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Psychiatric evaluation as the initial intervention is inappropriate because her low mood appears secondary to the functional impact of incontinence; the incontinence should be addressed first."
            },
            {
              "id": "B",
              "text": "Option B: Abdominal retropubic urethropexy is inappropriate because retropubic urethropexy treats stress incontinence, not urgency-predominant leakage."
            },
            {
              "id": "C",
              "text": "Option C: Periurethral bulking-agent injections is inappropriate because periurethral bulking procedures are used for stress incontinence due to outlet insufficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Psychiatric evaluation as the initial intervention is inappropriate because her low mood appears secondary to the functional impact of incontinence; the incontinence should be addressed first."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urodynamic testing before any treatment is inappropriate because urodynamic testing is not routinely required before initial conservative treatment of uncomplicated urge incontinence."
            },
            {
              "id": "B",
              "text": "Option B: Abdominal retropubic urethropexy is inappropriate because retropubic urethropexy treats stress incontinence, not urgency-predominant leakage."
            },
            {
              "id": "C",
              "text": "Option C: Periurethral bulking-agent injections is inappropriate because periurethral bulking procedures are used for stress incontinence due to outlet insufficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urodynamic testing before any treatment is inappropriate because urodynamic testing is not routinely required before initial conservative treatment of uncomplicated urge incontinence."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Surgical repair of the anterior vaginal wall prolapse is inappropriate because mild anterior vaginal wall prolapse is present, but the symptom pattern is urgency incontinence rather than prolapse-related obstruction or stress leakage. Prolapse surgery is invasive and does not replace initial bladder retraining for uncomplicated overactive bladder."
            },
            {
              "id": "B",
              "text": "Option B: Abdominal retropubic urethropexy is inappropriate because retropubic urethropexy treats stress incontinence, not urgency-predominant leakage."
            },
            {
              "id": "C",
              "text": "Option C: Periurethral bulking-agent injections is inappropriate because periurethral bulking procedures are used for stress incontinence due to outlet insufficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Surgical repair of the anterior vaginal wall prolapse is inappropriate because mild anterior vaginal wall prolapse is present, but the symptom pattern is urgency incontinence rather than prolapse-related obstruction or stress leakage. Prolapse surgery is invasive and does not replace initial bladder retraining for uncomplicated overactive bladder."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i013-tension-pneumothorax-decompression",
      "expectedHashes": {
        "ranaze_step3_uat": "b1fefad532c082f345a04e3029137a124809ec017cf73eb6b8867b5a8f666905",
        "ranaze_step3_prd": "b1fefad532c082f345a04e3029137a124809ec017cf73eb6b8867b5a8f666905"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase the respiratory rate of bag-valve ventilation is inappropriate because more vigorous ventilation does not relieve pleural pressure and can worsen a tension pneumothorax."
            },
            {
              "id": "B",
              "text": "Option C: Obtain a portable chest radiograph is inappropriate because imaging should not delay treatment when clinical findings indicate tension pneumothorax."
            },
            {
              "id": "C",
              "text": "Option D: Perform emergency cricothyrotomy is inappropriate because cricothyrotomy is indicated when an airway cannot be established, but this patient already has an endotracheal tube."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase the respiratory rate of bag-valve ventilation is inappropriate because more vigorous ventilation does not relieve pleural pressure and can worsen a tension pneumothorax."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a portable chest radiograph is inappropriate because imaging should not delay treatment when clinical findings indicate tension pneumothorax."
            },
            {
              "id": "B",
              "text": "Option B: Increase the respiratory rate of bag-valve ventilation is inappropriate because more vigorous ventilation does not relieve pleural pressure and can worsen a tension pneumothorax."
            },
            {
              "id": "C",
              "text": "Option D: Perform emergency cricothyrotomy is inappropriate because cricothyrotomy is indicated when an airway cannot be established, but this patient already has an endotracheal tube."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a portable chest radiograph is inappropriate because imaging should not delay treatment when clinical findings indicate tension pneumothorax."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform emergency cricothyrotomy is inappropriate because cricothyrotomy is indicated when an airway cannot be established, but this patient already has an endotracheal tube."
            },
            {
              "id": "B",
              "text": "Option B: Increase the respiratory rate of bag-valve ventilation is inappropriate because more vigorous ventilation does not relieve pleural pressure and can worsen a tension pneumothorax."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a portable chest radiograph is inappropriate because imaging should not delay treatment when clinical findings indicate tension pneumothorax."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform emergency cricothyrotomy is inappropriate because cricothyrotomy is indicated when an airway cannot be established, but this patient already has an endotracheal tube."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin positive end-expiratory pressure ventilation is inappropriate because positive end-expiratory pressure can further increase intrathoracic pressure and worsen hypotension."
            },
            {
              "id": "B",
              "text": "Option B: Increase the respiratory rate of bag-valve ventilation is inappropriate because more vigorous ventilation does not relieve pleural pressure and can worsen a tension pneumothorax."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a portable chest radiograph is inappropriate because imaging should not delay treatment when clinical findings indicate tension pneumothorax."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin positive end-expiratory pressure ventilation is inappropriate because positive end-expiratory pressure can further increase intrathoracic pressure and worsen hypotension."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a rapid intravenous crystalloid bolus alone is inappropriate because intravenous fluid may temporarily support circulation, but it cannot relieve obstructive shock caused by rising right pleural pressure. Immediate chest decompression must not be delayed."
            },
            {
              "id": "B",
              "text": "Option B: Increase the respiratory rate of bag-valve ventilation is inappropriate because more vigorous ventilation does not relieve pleural pressure and can worsen a tension pneumothorax."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a portable chest radiograph is inappropriate because imaging should not delay treatment when clinical findings indicate tension pneumothorax."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a rapid intravenous crystalloid bolus alone is inappropriate because intravenous fluid may temporarily support circulation, but it cannot relieve obstructive shock caused by rising right pleural pressure. Immediate chest decompression must not be delayed."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform pericardiocentesis is inappropriate because pericardiocentesis treats cardiac tamponade. Unilateral absent right breath sounds with contralateral tracheal deviation instead identifies a right tension pneumothorax requiring right pleural decompression."
            },
            {
              "id": "B",
              "text": "Option B: Increase the respiratory rate of bag-valve ventilation is inappropriate because more vigorous ventilation does not relieve pleural pressure and can worsen a tension pneumothorax."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a portable chest radiograph is inappropriate because imaging should not delay treatment when clinical findings indicate tension pneumothorax."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform pericardiocentesis is inappropriate because pericardiocentesis treats cardiac tamponade. Unilateral absent right breath sounds with contralateral tracheal deviation instead identifies a right tension pneumothorax requiring right pleural decompression."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i014-uncomplicated-cystitis-empiric-therapy",
      "expectedHashes": {
        "ranaze_step3_uat": "612a14631a97ba13a88f094c22023509cbca8b8973df8911297547c790fc840a",
        "ranaze_step3_prd": "612a14631a97ba13a88f094c22023509cbca8b8973df8911297547c790fc840a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "B",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            },
            {
              "id": "C",
              "text": "Option D: Order a complete blood count and coagulation studies is inappropriate because coagulation studies are not indicated; trace urine blood can occur with cystitis, and the urinalysis supports an infectious cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option D: Order a complete blood count and coagulation studies is inappropriate because coagulation studies are not indicated; trace urine blood can occur with cystitis, and the urinalysis supports an infectious cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order a complete blood count and coagulation studies is inappropriate because coagulation studies are not indicated; trace urine blood can occur with cystitis, and the urinalysis supports an infectious cause."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order a complete blood count and coagulation studies is inappropriate because coagulation studies are not indicated; trace urine blood can occur with cystitis, and the urinalysis supports an infectious cause."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend oral hydration and urine straining without antimicrobial therapy is inappropriate because hydration and urine straining alone do not treat the bacterial infection indicated by positive nitrites and leukocyte esterase."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend oral hydration and urine straining without antimicrobial therapy is inappropriate because hydration and urine straining alone do not treat the bacterial infection indicated by positive nitrites and leukocyte esterase."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a urine culture and withhold antimicrobial therapy until susceptibility results return is inappropriate because a culture may be appropriate for treatment failure, recurrence, pregnancy, or complicated infection, but this first typical episode can be treated empirically; withholding therapy pending culture is unnecessary."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a urine culture and withhold antimicrobial therapy until susceptibility results return is inappropriate because a culture may be appropriate for treatment failure, recurrence, pregnancy, or complicated infection, but this first typical episode can be treated empirically; withholding therapy pending culture is unnecessary."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hospitalize her for intravenous ceftriaxone treatment of acute pyelonephritis is inappropriate because she has neither fever, flank pain, vomiting, costovertebral angle tenderness, nor instability to suggest pyelonephritis requiring parenteral therapy or hospitalization."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hospitalize her for intravenous ceftriaxone treatment of acute pyelonephritis is inappropriate because she has neither fever, flank pain, vomiting, costovertebral angle tenderness, nor instability to suggest pyelonephritis requiring parenteral therapy or hospitalization."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe phenazopyridine alone for symptomatic relief is inappropriate because phenazopyridine may temporarily reduce dysuria but has no antibacterial activity and must not replace antimicrobial treatment of symptomatic bacterial cystitis."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe phenazopyridine alone for symptomatic relief is inappropriate because phenazopyridine may temporarily reduce dysuria but has no antibacterial activity and must not replace antimicrobial treatment of symptomatic bacterial cystitis."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a pelvic examination and vaginal pathogen testing before treating the urinary infection is inappropriate because her urinary frequency, urgency, dysuria, suprapubic tenderness, positive nitrites, and positive leukocyte esterase strongly support cystitis; the absence of vaginal discharge makes vaginitis less likely, so pelvic testing need not precede treatment."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a pelvic examination and vaginal pathogen testing before treating the urinary infection is inappropriate because her urinary frequency, urgency, dysuria, suprapubic tenderness, positive nitrites, and positive leukocyte esterase strongly support cystitis; the absence of vaginal discharge makes vaginitis less likely, so pelvic testing need not precede treatment."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe a 14-day course of broad-spectrum antimicrobial therapy is inappropriate because uncomplicated lower UTI is treated with a short oral regimen. Fourteen days of broad-spectrum therapy is excessive and adds avoidable adverse effects and selection pressure."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe a 14-day course of broad-spectrum antimicrobial therapy is inappropriate because uncomplicated lower UTI is treated with a short oral regimen. Fourteen days of broad-spectrum therapy is excessive and adds avoidable adverse effects and selection pressure."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat empirically with oral fluconazole for vulvovaginal candidiasis is inappropriate because fluconazole treats candidiasis, not the nitrite-positive bacterial lower urinary infection described here; she also has no vaginal discharge or rash suggesting vulvovaginal candidiasis."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a noncontrast CT scan of the abdomen and pelvis is inappropriate because cT is not indicated because she has no flank discomfort or other findings suggesting nephrolithiasis or an obstructing urinary tract process."
            },
            {
              "id": "C",
              "text": "Option C: Perform cystoscopy before initiating treatment is inappropriate because cystoscopy is not needed before treatment for a first, typical presentation of uncomplicated bacterial cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat empirically with oral fluconazole for vulvovaginal candidiasis is inappropriate because fluconazole treats candidiasis, not the nitrite-positive bacterial lower urinary infection described here; she also has no vaginal discharge or rash suggesting vulvovaginal candidiasis."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i015-aerobic-exercise-lipids",
      "expectedHashes": {
        "ranaze_step3_uat": "f2948149bb15c804643e715940ae303fa124f3b0a2c4c678880beb97b5d5d8fb",
        "ranaze_step3_prd": "f2948149bb15c804643e715940ae303fa124f3b0a2c4c678880beb97b5d5d8fb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Replace water aerobics with resistance training alone is inappropriate because resistance exercise has health benefits, but substituting it for aerobic activity alone is less effective for this lipid-focused goal."
            },
            {
              "id": "B",
              "text": "Option C: Continue the current weekly exercise schedule without change is inappropriate because his current once-weekly exercise volume is insufficient for optimal cardiovascular and lipid benefit."
            },
            {
              "id": "C",
              "text": "Option D: Avoid all dietary fat is inappropriate because eliminating all dietary fat is unnecessary and is inconsistent with a Mediterranean-style eating pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Replace water aerobics with resistance training alone is inappropriate because resistance exercise has health benefits, but substituting it for aerobic activity alone is less effective for this lipid-focused goal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue the current weekly exercise schedule without change is inappropriate because his current once-weekly exercise volume is insufficient for optimal cardiovascular and lipid benefit."
            },
            {
              "id": "B",
              "text": "Option B: Replace water aerobics with resistance training alone is inappropriate because resistance exercise has health benefits, but substituting it for aerobic activity alone is less effective for this lipid-focused goal."
            },
            {
              "id": "C",
              "text": "Option D: Avoid all dietary fat is inappropriate because eliminating all dietary fat is unnecessary and is inconsistent with a Mediterranean-style eating pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue the current weekly exercise schedule without change is inappropriate because his current once-weekly exercise volume is insufficient for optimal cardiovascular and lipid benefit."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Avoid all dietary fat is inappropriate because eliminating all dietary fat is unnecessary and is inconsistent with a Mediterranean-style eating pattern."
            },
            {
              "id": "B",
              "text": "Option B: Replace water aerobics with resistance training alone is inappropriate because resistance exercise has health benefits, but substituting it for aerobic activity alone is less effective for this lipid-focused goal."
            },
            {
              "id": "C",
              "text": "Option C: Continue the current weekly exercise schedule without change is inappropriate because his current once-weekly exercise volume is insufficient for optimal cardiovascular and lipid benefit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Avoid all dietary fat is inappropriate because eliminating all dietary fat is unnecessary and is inconsistent with a Mediterranean-style eating pattern."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop aerobic exercise and begin stretching exercises only is inappropriate because stretching does not provide the aerobic training needed to improve this lipid profile."
            },
            {
              "id": "B",
              "text": "Option B: Replace water aerobics with resistance training alone is inappropriate because resistance exercise has health benefits, but substituting it for aerobic activity alone is less effective for this lipid-focused goal."
            },
            {
              "id": "C",
              "text": "Option C: Continue the current weekly exercise schedule without change is inappropriate because his current once-weekly exercise volume is insufficient for optimal cardiovascular and lipid benefit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop aerobic exercise and begin stretching exercises only is inappropriate because stretching does not provide the aerobic training needed to improve this lipid profile."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an exercise stress test before recommending any increase in physical activity is inappropriate because routine stress testing is not required before moderate exercise in an asymptomatic person without exercise intolerance, and testing itself would not improve his lipid profile."
            },
            {
              "id": "B",
              "text": "Option B: Replace water aerobics with resistance training alone is inappropriate because resistance exercise has health benefits, but substituting it for aerobic activity alone is less effective for this lipid-focused goal."
            },
            {
              "id": "C",
              "text": "Option C: Continue the current weekly exercise schedule without change is inappropriate because his current once-weekly exercise volume is insufficient for optimal cardiovascular and lipid benefit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an exercise stress test before recommending any increase in physical activity is inappropriate because routine stress testing is not required before moderate exercise in an asymptomatic person without exercise intolerance, and testing itself would not improve his lipid profile."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin daily vitamin E supplementation instead of changing his exercise schedule is inappropriate because vitamin E supplementation is not a lipid-improving substitute for adequate physical activity and is not routinely recommended for cardiovascular prevention."
            },
            {
              "id": "B",
              "text": "Option B: Replace water aerobics with resistance training alone is inappropriate because resistance exercise has health benefits, but substituting it for aerobic activity alone is less effective for this lipid-focused goal."
            },
            {
              "id": "C",
              "text": "Option C: Continue the current weekly exercise schedule without change is inappropriate because his current once-weekly exercise volume is insufficient for optimal cardiovascular and lipid benefit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin daily vitamin E supplementation instead of changing his exercise schedule is inappropriate because vitamin E supplementation is not a lipid-improving substitute for adequate physical activity and is not routinely recommended for cardiovascular prevention."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin drinking alcohol daily to raise the HDL cholesterol concentration is inappropriate because alcohol should not be initiated as lipid therapy. Any HDL increase does not justify alcohol-related risks, and alcohol can increase triglycerides."
            },
            {
              "id": "B",
              "text": "Option B: Replace water aerobics with resistance training alone is inappropriate because resistance exercise has health benefits, but substituting it for aerobic activity alone is less effective for this lipid-focused goal."
            },
            {
              "id": "C",
              "text": "Option C: Continue the current weekly exercise schedule without change is inappropriate because his current once-weekly exercise volume is insufficient for optimal cardiovascular and lipid benefit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin drinking alcohol daily to raise the HDL cholesterol concentration is inappropriate because alcohol should not be initiated as lipid therapy. Any HDL increase does not justify alcohol-related risks, and alcohol can increase triglycerides."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i016-tinea-capitis-hepatotoxicity",
      "expectedHashes": {
        "ranaze_step3_uat": "4cb71977308fab5b3ee318fb3939ebaa47945f0ae6bf63e3af313f3328dea3f0",
        "ranaze_step3_prd": "4cb71977308fab5b3ee318fb3939ebaa47945f0ae6bf63e3af313f3328dea3f0"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary fibrosis is not a typical adverse effect of oral antifungal therapy for tinea capitis."
            },
            {
              "id": "B",
              "text": "Option C: Pancreatitis is not a characteristic toxicity of standard systemic therapy for tinea capitis."
            },
            {
              "id": "C",
              "text": "Option D: Seizures are not an expected adverse effect of the oral antifungal treatment used for this condition."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary fibrosis is not a typical adverse effect of oral antifungal therapy for tinea capitis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pancreatitis is not a characteristic toxicity of standard systemic therapy for tinea capitis."
            },
            {
              "id": "B",
              "text": "Option B: Pulmonary fibrosis is not a typical adverse effect of oral antifungal therapy for tinea capitis."
            },
            {
              "id": "C",
              "text": "Option D: Seizures are not an expected adverse effect of the oral antifungal treatment used for this condition."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pancreatitis is not a characteristic toxicity of standard systemic therapy for tinea capitis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Seizures are not an expected adverse effect of the oral antifungal treatment used for this condition."
            },
            {
              "id": "B",
              "text": "Option B: Pulmonary fibrosis is not a typical adverse effect of oral antifungal therapy for tinea capitis."
            },
            {
              "id": "C",
              "text": "Option C: Pancreatitis is not a characteristic toxicity of standard systemic therapy for tinea capitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Seizures are not an expected adverse effect of the oral antifungal treatment used for this condition."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aplastic anemia is not a typical toxicity of standard oral antifungal treatment for tinea capitis."
            },
            {
              "id": "B",
              "text": "Option B: Pulmonary fibrosis is not a typical adverse effect of oral antifungal therapy for tinea capitis."
            },
            {
              "id": "C",
              "text": "Option C: Pancreatitis is not a characteristic toxicity of standard systemic therapy for tinea capitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aplastic anemia is not a typical toxicity of standard oral antifungal treatment for tinea capitis."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i017-wrist-ganglion-natural-history",
      "expectedHashes": {
        "ranaze_step3_uat": "6ae734df02896cf4667863df516436cb8aab202da83435a8582377ebadc8ace4",
        "ranaze_step3_prd": "6ae734df02896cf4667863df516436cb8aab202da83435a8582377ebadc8ace4"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Progressive, disabling wrist pain is inappropriate because pain can occur with a ganglion cyst, but steadily progressive disabling pain is not its usual untreated course."
            },
            {
              "id": "B",
              "text": "Option B: Transformation into a malignant tumor is inappropriate because ganglion cysts are benign and do not undergo malignant transformation."
            },
            {
              "id": "C",
              "text": "Option C: Compression neuropathy of the radial nerve is inappropriate because nerve compression is uncommon, especially with a small dorsal cyst and normal strength and sensation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Progressive, disabling wrist pain is inappropriate because pain can occur with a ganglion cyst, but steadily progressive disabling pain is not its usual untreated course."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transformation into a malignant tumor is inappropriate because ganglion cysts are benign and do not undergo malignant transformation."
            },
            {
              "id": "B",
              "text": "Option A: Progressive, disabling wrist pain is inappropriate because pain can occur with a ganglion cyst, but steadily progressive disabling pain is not its usual untreated course."
            },
            {
              "id": "C",
              "text": "Option C: Compression neuropathy of the radial nerve is inappropriate because nerve compression is uncommon, especially with a small dorsal cyst and normal strength and sensation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transformation into a malignant tumor is inappropriate because ganglion cysts are benign and do not undergo malignant transformation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Compression neuropathy of the radial nerve is inappropriate because nerve compression is uncommon, especially with a small dorsal cyst and normal strength and sensation."
            },
            {
              "id": "B",
              "text": "Option A: Progressive, disabling wrist pain is inappropriate because pain can occur with a ganglion cyst, but steadily progressive disabling pain is not its usual untreated course."
            },
            {
              "id": "C",
              "text": "Option B: Transformation into a malignant tumor is inappropriate because ganglion cysts are benign and do not undergo malignant transformation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Compression neuropathy of the radial nerve is inappropriate because nerve compression is uncommon, especially with a small dorsal cyst and normal strength and sensation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Spontaneous bacterial infection is inappropriate because an untreated closed ganglion cyst does not usually become infected."
            },
            {
              "id": "B",
              "text": "Option A: Progressive, disabling wrist pain is inappropriate because pain can occur with a ganglion cyst, but steadily progressive disabling pain is not its usual untreated course."
            },
            {
              "id": "C",
              "text": "Option B: Transformation into a malignant tumor is inappropriate because ganglion cysts are benign and do not undergo malignant transformation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Spontaneous bacterial infection is inappropriate because an untreated closed ganglion cyst does not usually become infected."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Steady enlargement into a fixed solid mass is inappropriate because ganglion cysts characteristically fluctuate in size and may even disappear; steady transformation into a fixed solid mass is not their expected natural history."
            },
            {
              "id": "B",
              "text": "Option A: Progressive, disabling wrist pain is inappropriate because pain can occur with a ganglion cyst, but steadily progressive disabling pain is not its usual untreated course."
            },
            {
              "id": "C",
              "text": "Option B: Transformation into a malignant tumor is inappropriate because ganglion cysts are benign and do not undergo malignant transformation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Steady enlargement into a fixed solid mass is inappropriate because ganglion cysts characteristically fluctuate in size and may even disappear; steady transformation into a fixed solid mass is not their expected natural history."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i019-low-grade-spondylolisthesis-management",
      "expectedHashes": {
        "ranaze_step3_uat": "423a99bd1a7bcc5abbef52bb5187fe20383be2db1480aa698b1d6ac67fe98efc",
        "ranaze_step3_prd": "423a99bd1a7bcc5abbef52bb5187fe20383be2db1480aa698b1d6ac67fe98efc"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a CT scan of the lumbar spine is inappropriate because cT can better define osseous anatomy but is not needed for an already identified stable low-grade slip without concerning features."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a bone density study is inappropriate because bone density testing is not indicated in an otherwise healthy adolescent with this radiographic finding."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an MRI of the lumbar spine is inappropriate because mRI is indicated for neurologic deficits, radicular symptoms, or concern for another structural cause, none of which is present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a CT scan of the lumbar spine is inappropriate because cT can better define osseous anatomy but is not needed for an already identified stable low-grade slip without concerning features."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a bone density study is inappropriate because bone density testing is not indicated in an otherwise healthy adolescent with this radiographic finding."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a CT scan of the lumbar spine is inappropriate because cT can better define osseous anatomy but is not needed for an already identified stable low-grade slip without concerning features."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an MRI of the lumbar spine is inappropriate because mRI is indicated for neurologic deficits, radicular symptoms, or concern for another structural cause, none of which is present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a bone density study is inappropriate because bone density testing is not indicated in an otherwise healthy adolescent with this radiographic finding."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an MRI of the lumbar spine is inappropriate because mRI is indicated for neurologic deficits, radicular symptoms, or concern for another structural cause, none of which is present."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a CT scan of the lumbar spine is inappropriate because cT can better define osseous anatomy but is not needed for an already identified stable low-grade slip without concerning features."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a bone density study is inappropriate because bone density testing is not indicated in an otherwise healthy adolescent with this radiographic finding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an MRI of the lumbar spine is inappropriate because mRI is indicated for neurologic deficits, radicular symptoms, or concern for another structural cause, none of which is present."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer immediately for spinal fusion is inappropriate because spinal fusion is reserved for selected patients with refractory pain, progression, or neurologic compromise."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a CT scan of the lumbar spine is inappropriate because cT can better define osseous anatomy but is not needed for an already identified stable low-grade slip without concerning features."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a bone density study is inappropriate because bone density testing is not indicated in an otherwise healthy adolescent with this radiographic finding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer immediately for spinal fusion is inappropriate because spinal fusion is reserved for selected patients with refractory pain, progression, or neurologic compromise."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a lumbar epidural glucocorticoid injection is inappropriate because epidural glucocorticoid injections are directed at radicular pain from nerve-root inflammation. He has no leg pain, sensory change, weakness, or reflex abnormality."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a CT scan of the lumbar spine is inappropriate because cT can better define osseous anatomy but is not needed for an already identified stable low-grade slip without concerning features."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a bone density study is inappropriate because bone density testing is not indicated in an otherwise healthy adolescent with this radiographic finding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a lumbar epidural glucocorticoid injection is inappropriate because epidural glucocorticoid injections are directed at radicular pain from nerve-root inflammation. He has no leg pain, sensory change, weakness, or reflex abnormality."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a radionuclide bone scan is inappropriate because bone scintigraphy can help identify an occult active pars stress injury, but radiographs have already established grade 1 L5-on-S1 spondylolisthesis and the result would not change initial conservative management."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a CT scan of the lumbar spine is inappropriate because cT can better define osseous anatomy but is not needed for an already identified stable low-grade slip without concerning features."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a bone density study is inappropriate because bone density testing is not indicated in an otherwise healthy adolescent with this radiographic finding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a radionuclide bone scan is inappropriate because bone scintigraphy can help identify an occult active pars stress injury, but radiographs have already established grade 1 L5-on-S1 spondylolisthesis and the result would not change initial conservative management."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed immediately with direct repair of the pars defect is inappropriate because direct pars repair is an operative option for selected patients with persistent disabling symptoms despite comprehensive nonsurgical treatment. Mild intermittent pain without neurologic compromise does not justify immediate surgery."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a CT scan of the lumbar spine is inappropriate because cT can better define osseous anatomy but is not needed for an already identified stable low-grade slip without concerning features."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a bone density study is inappropriate because bone density testing is not indicated in an otherwise healthy adolescent with this radiographic finding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed immediately with direct repair of the pars defect is inappropriate because direct pars repair is an operative option for selected patients with persistent disabling symptoms despite comprehensive nonsurgical treatment. Mild intermittent pain without neurologic compromise does not justify immediate surgery."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i020-monocular-vision-loss-fundus-exam",
      "expectedHashes": {
        "ranaze_step3_uat": "564540fe845b9dfab77b070ce7e9bcd1b2a2e2b5604bf42ffdceecf029a9e6e5",
        "ranaze_step3_prd": "564540fe845b9dfab77b070ce7e9bcd1b2a2e2b5604bf42ffdceecf029a9e6e5"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform optic nerve sheath decompression is inappropriate because optic nerve sheath decompression is not an initial diagnostic step for painless monocular visual loss."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a temporal artery biopsy is inappropriate because temporal artery biopsy is appropriate when giant cell arteritis is strongly suspected, but this patient lacks typical cranial symptoms and first needs ocular evaluation."
            },
            {
              "id": "C",
              "text": "Option D: Obtain an MRI of the brain is inappropriate because brain MRI is not the first test when the presentation is isolated monocular vision loss without focal neurologic deficits."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform optic nerve sheath decompression is inappropriate because optic nerve sheath decompression is not an initial diagnostic step for painless monocular visual loss."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a temporal artery biopsy is inappropriate because temporal artery biopsy is appropriate when giant cell arteritis is strongly suspected, but this patient lacks typical cranial symptoms and first needs ocular evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Perform optic nerve sheath decompression is inappropriate because optic nerve sheath decompression is not an initial diagnostic step for painless monocular visual loss."
            },
            {
              "id": "C",
              "text": "Option D: Obtain an MRI of the brain is inappropriate because brain MRI is not the first test when the presentation is isolated monocular vision loss without focal neurologic deficits."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a temporal artery biopsy is inappropriate because temporal artery biopsy is appropriate when giant cell arteritis is strongly suspected, but this patient lacks typical cranial symptoms and first needs ocular evaluation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an MRI of the brain is inappropriate because brain MRI is not the first test when the presentation is isolated monocular vision loss without focal neurologic deficits."
            },
            {
              "id": "B",
              "text": "Option A: Perform optic nerve sheath decompression is inappropriate because optic nerve sheath decompression is not an initial diagnostic step for painless monocular visual loss."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a temporal artery biopsy is inappropriate because temporal artery biopsy is appropriate when giant cell arteritis is strongly suspected, but this patient lacks typical cranial symptoms and first needs ocular evaluation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an MRI of the brain is inappropriate because brain MRI is not the first test when the presentation is isolated monocular vision loss without focal neurologic deficits."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start high-dose glucocorticoid therapy is inappropriate because empiric high-dose glucocorticoids are used when giant cell arteritis is strongly suspected, which is not established here."
            },
            {
              "id": "B",
              "text": "Option A: Perform optic nerve sheath decompression is inappropriate because optic nerve sheath decompression is not an initial diagnostic step for painless monocular visual loss."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a temporal artery biopsy is inappropriate because temporal artery biopsy is appropriate when giant cell arteritis is strongly suspected, but this patient lacks typical cranial symptoms and first needs ocular evaluation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start high-dose glucocorticoid therapy is inappropriate because empiric high-dose glucocorticoids are used when giant cell arteritis is strongly suspected, which is not established here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure intraocular pressure is inappropriate because tonometry is important when acute angle-closure glaucoma is suspected, but this presentation is painless, with reactive pupils and a normal external examination. It also would not directly evaluate the retinal and optic-nerve causes suggested by painless monocular visual loss."
            },
            {
              "id": "B",
              "text": "Option A: Perform optic nerve sheath decompression is inappropriate because optic nerve sheath decompression is not an initial diagnostic step for painless monocular visual loss."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a temporal artery biopsy is inappropriate because temporal artery biopsy is appropriate when giant cell arteritis is strongly suspected, but this patient lacks typical cranial symptoms and first needs ocular evaluation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure intraocular pressure is inappropriate because tonometry is important when acute angle-closure glaucoma is suspected, but this presentation is painless, with reactive pupils and a normal external examination. It also would not directly evaluate the retinal and optic-nerve causes suggested by painless monocular visual loss."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i021-alcohol-withdrawal-delirium",
      "expectedHashes": {
        "ranaze_step3_uat": "18368c2b12ef2ebbd72e914e41fc823e7a0cfcd82a8ddeda8439b06538f0da26",
        "ranaze_step3_prd": "18368c2b12ef2ebbd72e914e41fc823e7a0cfcd82a8ddeda8439b06538f0da26"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV haloperidol is inappropriate because haloperidol may be used only as an adjunct for persistent agitation or psychosis; it does not treat alcohol withdrawal and can lower the seizure threshold."
            },
            {
              "id": "B",
              "text": "Option C: IV naloxone is inappropriate because naloxone reverses opioid intoxication, which typically causes respiratory depression and miosis rather than autonomic hyperactivity and tremor."
            },
            {
              "id": "C",
              "text": "Option D: Oral hydroxyzine is inappropriate because hydroxyzine is not adequate treatment for severe alcohol withdrawal and does not prevent withdrawal seizures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV haloperidol is inappropriate because haloperidol may be used only as an adjunct for persistent agitation or psychosis; it does not treat alcohol withdrawal and can lower the seizure threshold."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV naloxone is inappropriate because naloxone reverses opioid intoxication, which typically causes respiratory depression and miosis rather than autonomic hyperactivity and tremor."
            },
            {
              "id": "B",
              "text": "Option B: IV haloperidol is inappropriate because haloperidol may be used only as an adjunct for persistent agitation or psychosis; it does not treat alcohol withdrawal and can lower the seizure threshold."
            },
            {
              "id": "C",
              "text": "Option D: Oral hydroxyzine is inappropriate because hydroxyzine is not adequate treatment for severe alcohol withdrawal and does not prevent withdrawal seizures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV naloxone is inappropriate because naloxone reverses opioid intoxication, which typically causes respiratory depression and miosis rather than autonomic hyperactivity and tremor."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral hydroxyzine is inappropriate because hydroxyzine is not adequate treatment for severe alcohol withdrawal and does not prevent withdrawal seizures."
            },
            {
              "id": "B",
              "text": "Option B: IV haloperidol is inappropriate because haloperidol may be used only as an adjunct for persistent agitation or psychosis; it does not treat alcohol withdrawal and can lower the seizure threshold."
            },
            {
              "id": "C",
              "text": "Option C: IV naloxone is inappropriate because naloxone reverses opioid intoxication, which typically causes respiratory depression and miosis rather than autonomic hyperactivity and tremor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral hydroxyzine is inappropriate because hydroxyzine is not adequate treatment for severe alcohol withdrawal and does not prevent withdrawal seizures."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV physostigmine is inappropriate because physostigmine is used for severe anticholinergic toxicity, which causes dry skin and mucosa rather than diaphoresis."
            },
            {
              "id": "B",
              "text": "Option B: IV haloperidol is inappropriate because haloperidol may be used only as an adjunct for persistent agitation or psychosis; it does not treat alcohol withdrawal and can lower the seizure threshold."
            },
            {
              "id": "C",
              "text": "Option C: IV naloxone is inappropriate because naloxone reverses opioid intoxication, which typically causes respiratory depression and miosis rather than autonomic hyperactivity and tremor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV physostigmine is inappropriate because physostigmine is used for severe anticholinergic toxicity, which causes dry skin and mucosa rather than diaphoresis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV thiamine is inappropriate because parenteral thiamine is appropriate supportive therapy for a patient at risk from chronic alcohol use, but it does not rapidly control withdrawal delirium, autonomic hyperactivity, or seizure risk. IV benzodiazepine treatment must not be displaced."
            },
            {
              "id": "B",
              "text": "Option B: IV haloperidol is inappropriate because haloperidol may be used only as an adjunct for persistent agitation or psychosis; it does not treat alcohol withdrawal and can lower the seizure threshold."
            },
            {
              "id": "C",
              "text": "Option C: IV naloxone is inappropriate because naloxone reverses opioid intoxication, which typically causes respiratory depression and miosis rather than autonomic hyperactivity and tremor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV thiamine is inappropriate because parenteral thiamine is appropriate supportive therapy for a patient at risk from chronic alcohol use, but it does not rapidly control withdrawal delirium, autonomic hyperactivity, or seizure risk. IV benzodiazepine treatment must not be displaced."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV clonidine is inappropriate because clonidine can reduce autonomic symptoms only as an adjunct. Alpha-2 agonists do not treat the underlying withdrawal delirium or prevent withdrawal seizures and are not recommended for alcohol-withdrawal delirium."
            },
            {
              "id": "B",
              "text": "Option B: IV haloperidol is inappropriate because haloperidol may be used only as an adjunct for persistent agitation or psychosis; it does not treat alcohol withdrawal and can lower the seizure threshold."
            },
            {
              "id": "C",
              "text": "Option C: IV naloxone is inappropriate because naloxone reverses opioid intoxication, which typically causes respiratory depression and miosis rather than autonomic hyperactivity and tremor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV clonidine is inappropriate because clonidine can reduce autonomic symptoms only as an adjunct. Alpha-2 agonists do not treat the underlying withdrawal delirium or prevent withdrawal seizures and are not recommended for alcohol-withdrawal delirium."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV phenytoin is inappropriate because phenytoin does not prevent or treat alcohol-withdrawal seizures unless the patient has a separate seizure disorder, and it does not control the current withdrawal delirium."
            },
            {
              "id": "B",
              "text": "Option B: IV haloperidol is inappropriate because haloperidol may be used only as an adjunct for persistent agitation or psychosis; it does not treat alcohol withdrawal and can lower the seizure threshold."
            },
            {
              "id": "C",
              "text": "Option C: IV naloxone is inappropriate because naloxone reverses opioid intoxication, which typically causes respiratory depression and miosis rather than autonomic hyperactivity and tremor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV phenytoin is inappropriate because phenytoin does not prevent or treat alcohol-withdrawal seizures unless the patient has a separate seizure disorder, and it does not control the current withdrawal delirium."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i023-central-line-bloodstream-infection",
      "expectedHashes": {
        "ranaze_step3_uat": "00051e2ae01fa358082bc455c496ebb28200598868a2bc5b6a307ad9cfb8f839",
        "ranaze_step3_prd": "00051e2ae01fa358082bc455c496ebb28200598868a2bc5b6a307ad9cfb8f839"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "B",
              "text": "Option C: IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            },
            {
              "id": "C",
              "text": "Option D: IV methylprednisolone is inappropriate because methylprednisolone would increase immunosuppression and does not treat a suspected bloodstream infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            },
            {
              "id": "B",
              "text": "Option B: IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "C",
              "text": "Option D: IV methylprednisolone is inappropriate because methylprednisolone would increase immunosuppression and does not treat a suspected bloodstream infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV methylprednisolone is inappropriate because methylprednisolone would increase immunosuppression and does not treat a suspected bloodstream infection."
            },
            {
              "id": "B",
              "text": "Option B: IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "C",
              "text": "Option C: IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV methylprednisolone is inappropriate because methylprednisolone would increase immunosuppression and does not treat a suspected bloodstream infection."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No additional antimicrobial therapy is inappropriate because additional gram-positive coverage is indicated because the central catheter is a likely source of bacteremia."
            },
            {
              "id": "B",
              "text": "Option B: IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "C",
              "text": "Option C: IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No additional antimicrobial therapy is inappropriate because additional gram-positive coverage is indicated because the central catheter is a likely source of bacteremia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV cefazolin is inappropriate because cefazolin covers methicillin-susceptible staphylococci but is unreliable against MRSA and therefore should not replace empiric IV vancomycin before culture susceptibilities are known."
            },
            {
              "id": "B",
              "text": "Option B: IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "C",
              "text": "Option C: IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV cefazolin is inappropriate because cefazolin covers methicillin-susceptible staphylococci but is unreliable against MRSA and therefore should not replace empiric IV vancomycin before culture susceptibilities are known."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV linezolid is inappropriate because although linezolid covers MRSA, IDSA specifically advises against using it empirically for suspected but unproven catheter-related bloodstream infection."
            },
            {
              "id": "B",
              "text": "Option B: IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "C",
              "text": "Option C: IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV linezolid is inappropriate because although linezolid covers MRSA, IDSA specifically advises against using it empirically for suspected but unproven catheter-related bloodstream infection."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral vancomycin does not achieve reliable systemic concentrations and cannot treat a bloodstream infection; the required route is intravenous."
            },
            {
              "id": "B",
              "text": "Option B: IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "C",
              "text": "Option C: IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral vancomycin does not achieve reliable systemic concentrations and cannot treat a bloodstream infection; the required route is intravenous."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV gentamicin is inappropriate because gentamicin principally adds gram-negative activity and nephrotoxicity risk but does not provide adequate independent coverage of the methicillin-resistant staphylococci central to this presentation."
            },
            {
              "id": "B",
              "text": "Option B: IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "C",
              "text": "Option C: IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV gentamicin is inappropriate because gentamicin principally adds gram-negative activity and nephrotoxicity risk but does not provide adequate independent coverage of the methicillin-resistant staphylococci central to this presentation."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV cefepime is inappropriate because cefepime supplies broad gram-negative coverage, which levofloxacin is already providing, but does not reliably cover MRSA; it therefore fails to supply the principal missing component of this regimen."
            },
            {
              "id": "B",
              "text": "Option B: IV amphotericin B is inappropriate because amphotericin B is not routine empiric therapy for a stable patient with suspected bacterial catheter-related bloodstream infection."
            },
            {
              "id": "C",
              "text": "Option C: IV fluconazole is inappropriate because fluconazole may be indicated for selected suspected or documented candidemia but does not provide the needed empiric gram-positive catheter coverage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV cefepime is inappropriate because cefepime supplies broad gram-negative coverage, which levofloxacin is already providing, but does not reliably cover MRSA; it therefore fails to supply the principal missing component of this regimen."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i024-atrial-fibrillation-rate-control",
      "expectedHashes": {
        "ranaze_step3_uat": "d8fce2f38c7e6639dd8d17ed3782dd731d7b05b0eaef0c540f4ff711f2ae83aa",
        "ranaze_step3_prd": "d8fce2f38c7e6639dd8d17ed3782dd731d7b05b0eaef0c540f4ff711f2ae83aa"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
            },
            {
              "id": "B",
              "text": "Option C: Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
            },
            {
              "id": "C",
              "text": "Option D: Potassium chloride is not indicated because the potassium concentration is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
            },
            {
              "id": "B",
              "text": "Option B: Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option D: Potassium chloride is not indicated because the potassium concentration is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Potassium chloride is not indicated because the potassium concentration is normal."
            },
            {
              "id": "B",
              "text": "Option B: Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option C: Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Potassium chloride is not indicated because the potassium concentration is normal."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Procainamide is primarily used for selected tachyarrhythmias, including preexcited atrial fibrillation; this ECG has no delta waves."
            },
            {
              "id": "B",
              "text": "Option B: Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option C: Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Procainamide is primarily used for selected tachyarrhythmias, including preexcited atrial fibrillation; this ECG has no delta waves."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Adenosine can transiently block the AV node and terminate AV-node-dependent regular supraventricular tachycardia, but it does not convert atrial fibrillation or provide sustained rate control."
            },
            {
              "id": "B",
              "text": "Option B: Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option C: Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Adenosine can transiently block the AV node and terminate AV-node-dependent regular supraventricular tachycardia, but it does not convert atrial fibrillation or provide sustained rate control."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV digoxin can reduce ventricular rate, but its onset is substantially slower and it is less effective than diltiazem for rapid acute control in this stable patient without heart failure or intolerance of first-line AV-nodal blockers."
            },
            {
              "id": "B",
              "text": "Option B: Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option C: Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV digoxin can reduce ventricular rate, but its onset is substantially slower and it is less effective than diltiazem for rapid acute control in this stable patient without heart failure or intolerance of first-line AV-nodal blockers."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV amiodarone is generally reserved for critically ill patients or those with decompensated heart failure in whom beta blockers and nondihydropyridine calcium-channel blockers are ineffective or contraindicated; neither condition is present."
            },
            {
              "id": "B",
              "text": "Option B: Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option C: Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV amiodarone is generally reserved for critically ill patients or those with decompensated heart failure in whom beta blockers and nondihydropyridine calcium-channel blockers are ineffective or contraindicated; neither condition is present."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anticoagulation may be considered after stroke-risk and cardioversion planning, but unfractionated heparin does not slow the current ventricular rate and is not the most appropriate immediate medication requested."
            },
            {
              "id": "B",
              "text": "Option B: Calcium gluconate is used for cardioprotection in severe hyperkalemia or certain toxicities, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option C: Magnesium sulfate is not indicated because the magnesium level is normal and the rhythm is atrial fibrillation rather than torsades de pointes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anticoagulation may be considered after stroke-risk and cardioversion planning, but unfractionated heparin does not slow the current ventricular rate and is not the most appropriate immediate medication requested."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i026-recurrent-viral-infections",
      "expectedHashes": {
        "ranaze_step3_uat": "b152c1a8ba406bd3a25169eb78db9e634d5c2b487b33aedd0553722548824fa8",
        "ranaze_step3_prd": "b152c1a8ba406bd3a25169eb78db9e634d5c2b487b33aedd0553722548824fa8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Her pattern requires immediate evaluation for a primary immunodeficiency is inappropriate because frequent uncomplicated respiratory infections alone are common in preschool children and do not establish immunodeficiency."
            },
            {
              "id": "B",
              "text": "Option C: The recurrent illnesses most likely reflect failure to metabolize antibiotics is inappropriate because antibiotic metabolism does not explain repeated mostly viral respiratory illnesses."
            },
            {
              "id": "C",
              "text": "Option D: The illnesses suggest infection with an unusually virulent bacterial strain is inappropriate because repeated episodes with only one prior positive streptococcal culture do not suggest a persistently virulent bacterial strain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Her pattern requires immediate evaluation for a primary immunodeficiency is inappropriate because frequent uncomplicated respiratory infections alone are common in preschool children and do not establish immunodeficiency."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The recurrent illnesses most likely reflect failure to metabolize antibiotics is inappropriate because antibiotic metabolism does not explain repeated mostly viral respiratory illnesses."
            },
            {
              "id": "B",
              "text": "Option A: Her pattern requires immediate evaluation for a primary immunodeficiency is inappropriate because frequent uncomplicated respiratory infections alone are common in preschool children and do not establish immunodeficiency."
            },
            {
              "id": "C",
              "text": "Option D: The illnesses suggest infection with an unusually virulent bacterial strain is inappropriate because repeated episodes with only one prior positive streptococcal culture do not suggest a persistently virulent bacterial strain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The recurrent illnesses most likely reflect failure to metabolize antibiotics is inappropriate because antibiotic metabolism does not explain repeated mostly viral respiratory illnesses."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The illnesses suggest infection with an unusually virulent bacterial strain is inappropriate because repeated episodes with only one prior positive streptococcal culture do not suggest a persistently virulent bacterial strain."
            },
            {
              "id": "B",
              "text": "Option A: Her pattern requires immediate evaluation for a primary immunodeficiency is inappropriate because frequent uncomplicated respiratory infections alone are common in preschool children and do not establish immunodeficiency."
            },
            {
              "id": "C",
              "text": "Option C: The recurrent illnesses most likely reflect failure to metabolize antibiotics is inappropriate because antibiotic metabolism does not explain repeated mostly viral respiratory illnesses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The illnesses suggest infection with an unusually virulent bacterial strain is inappropriate because repeated episodes with only one prior positive streptococcal culture do not suggest a persistently virulent bacterial strain."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The pattern is most suggestive of a pet-associated systemic infection is inappropriate because the history supports ordinary exposure to respiratory viruses in childcare, not pet-associated systemic infection."
            },
            {
              "id": "B",
              "text": "Option A: Her pattern requires immediate evaluation for a primary immunodeficiency is inappropriate because frequent uncomplicated respiratory infections alone are common in preschool children and do not establish immunodeficiency."
            },
            {
              "id": "C",
              "text": "Option C: The recurrent illnesses most likely reflect failure to metabolize antibiotics is inappropriate because antibiotic metabolism does not explain repeated mostly viral respiratory illnesses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The pattern is most suggestive of a pet-associated systemic infection is inappropriate because the history supports ordinary exposure to respiratory viruses in childcare, not pet-associated systemic infection."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin empiric amoxicillin for each respiratory illness is inappropriate because rhinorrhea, cough, and sore throat during brief, recurrent illnesses are typical viral URI features. Antibiotics do not treat uncomplicated viral URIs, and only one previous illness had documented group A streptococcus."
            },
            {
              "id": "B",
              "text": "Option A: Her pattern requires immediate evaluation for a primary immunodeficiency is inappropriate because frequent uncomplicated respiratory infections alone are common in preschool children and do not establish immunodeficiency."
            },
            {
              "id": "C",
              "text": "Option C: The recurrent illnesses most likely reflect failure to metabolize antibiotics is inappropriate because antibiotic metabolism does not explain repeated mostly viral respiratory illnesses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin empiric amoxicillin for each respiratory illness is inappropriate because rhinorrhea, cough, and sore throat during brief, recurrent illnesses are typical viral URI features. Antibiotics do not treat uncomplicated viral URIs, and only one previous illness had documented group A streptococcus."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer her for tonsillectomy because of recurrent pharyngitis is inappropriate because six mixed respiratory illnesses are not six documented episodes of recurrent streptococcal tonsillitis. Only one throat culture grew group A streptococcus, so the history does not justify tonsillectomy."
            },
            {
              "id": "B",
              "text": "Option A: Her pattern requires immediate evaluation for a primary immunodeficiency is inappropriate because frequent uncomplicated respiratory infections alone are common in preschool children and do not establish immunodeficiency."
            },
            {
              "id": "C",
              "text": "Option C: The recurrent illnesses most likely reflect failure to metabolize antibiotics is inappropriate because antibiotic metabolism does not explain repeated mostly viral respiratory illnesses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer her for tonsillectomy because of recurrent pharyngitis is inappropriate because six mixed respiratory illnesses are not six documented episodes of recurrent streptococcal tonsillitis. Only one throat culture grew group A streptococcus, so the history does not justify tonsillectomy."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diagnose allergic rhinitis and begin a daily antihistamine is inappropriate because allergic rhinitis can cause chronic rhinorrhea but does not explain repeated febrile acute illnesses with tender cervical nodes and sore throat."
            },
            {
              "id": "B",
              "text": "Option A: Her pattern requires immediate evaluation for a primary immunodeficiency is inappropriate because frequent uncomplicated respiratory infections alone are common in preschool children and do not establish immunodeficiency."
            },
            {
              "id": "C",
              "text": "Option C: The recurrent illnesses most likely reflect failure to metabolize antibiotics is inappropriate because antibiotic metabolism does not explain repeated mostly viral respiratory illnesses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diagnose allergic rhinitis and begin a daily antihistamine is inappropriate because allergic rhinitis can cause chronic rhinorrhea but does not explain repeated febrile acute illnesses with tender cervical nodes and sore throat."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i027-bph-alpha-blocker",
      "expectedHashes": {
        "ranaze_step3_uat": "f660e021eecec52ac965916aa1566c8a6764c8015e4027c09e628bc7aeeb4d4f",
        "ranaze_step3_prd": "f660e021eecec52ac965916aa1566c8a6764c8015e4027c09e628bc7aeeb4d4f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
            },
            {
              "id": "B",
              "text": "Option B: Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
            },
            {
              "id": "C",
              "text": "Option D: Schedule transurethral resection of the prostate is inappropriate because surgery is generally reserved for refractory symptoms or complications such as recurrent retention, stones, infections, or renal impairment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
            },
            {
              "id": "B",
              "text": "Option A: Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
            },
            {
              "id": "C",
              "text": "Option D: Schedule transurethral resection of the prostate is inappropriate because surgery is generally reserved for refractory symptoms or complications such as recurrent retention, stones, infections, or renal impairment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule transurethral resection of the prostate is inappropriate because surgery is generally reserved for refractory symptoms or complications such as recurrent retention, stones, infections, or renal impairment."
            },
            {
              "id": "B",
              "text": "Option A: Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
            },
            {
              "id": "C",
              "text": "Option B: Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule transurethral resection of the prostate is inappropriate because surgery is generally reserved for refractory symptoms or complications such as recurrent retention, stones, infections, or renal impairment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide reassurance and reassess without treatment in 1 month is inappropriate because his symptoms are bothersome and progressive, and he requests treatment."
            },
            {
              "id": "B",
              "text": "Option A: Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
            },
            {
              "id": "C",
              "text": "Option B: Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide reassurance and reassess without treatment in 1 month is inappropriate because his symptoms are bothersome and progressive, and he requests treatment."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform transrectal prostate biopsy is inappropriate because a smooth, diffusely enlarged prostate and reference-range PSA support BPH rather than prostate cancer. Biopsy is not the next step without a suspicious nodule, PSA abnormality, or other cancer concern."
            },
            {
              "id": "B",
              "text": "Option A: Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
            },
            {
              "id": "C",
              "text": "Option B: Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform transrectal prostate biopsy is inappropriate because a smooth, diffusely enlarged prostate and reference-range PSA support BPH rather than prostate cancer. Biopsy is not the next step without a suspicious nodule, PSA abnormality, or other cancer concern."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin empiric ciprofloxacin for chronic bacterial prostatitis is inappropriate because chronic bacterial prostatitis generally causes recurrent urinary infection, pelvic discomfort, or inflammatory urine findings. This patient has no dysuria, fever, or urinalysis abnormality."
            },
            {
              "id": "B",
              "text": "Option A: Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
            },
            {
              "id": "C",
              "text": "Option B: Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin empiric ciprofloxacin for chronic bacterial prostatitis is inappropriate because chronic bacterial prostatitis generally causes recurrent urinary infection, pelvic discomfort, or inflammatory urine findings. This patient has no dysuria, fever, or urinalysis abnormality."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin desmopressin at bedtime for nocturia is inappropriate because desmopressin targets nocturnal polyuria and can cause hyponatremia. It does not relieve the prostate-mediated obstruction causing hesitancy, weak stream, and incomplete emptying."
            },
            {
              "id": "B",
              "text": "Option A: Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
            },
            {
              "id": "C",
              "text": "Option B: Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin desmopressin at bedtime for nocturia is inappropriate because desmopressin targets nocturnal polyuria and can cause hyponatremia. It does not relieve the prostate-mediated obstruction causing hesitancy, weak stream, and incomplete emptying."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform cystoscopy before initiating treatment is inappropriate because routine cystoscopy is unnecessary before initial medical treatment of uncomplicated, clinically apparent BPH; there is no hematuria, infection, or other finding requiring lower-tract visualization."
            },
            {
              "id": "B",
              "text": "Option A: Begin finasteride therapy is inappropriate because finasteride can reduce prostate size but generally requires months for clinical benefit."
            },
            {
              "id": "C",
              "text": "Option B: Begin oxybutynin therapy is inappropriate because oxybutynin can worsen urinary retention in bladder outlet obstruction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform cystoscopy before initiating treatment is inappropriate because routine cystoscopy is unnecessary before initial medical treatment of uncomplicated, clinically apparent BPH; there is no hematuria, infection, or other finding requiring lower-tract visualization."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i028-sarcoidosis-chest-radiograph",
      "expectedHashes": {
        "ranaze_step3_uat": "12a5c299a766879e295168344f66d7363ec68600483a9ab323047f59e5bbb053",
        "ranaze_step3_prd": "12a5c299a766879e295168344f66d7363ec68600483a9ab323047f59e5bbb053"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "B",
              "text": "Option C: Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            },
            {
              "id": "C",
              "text": "Option D: Repeat serum calcium measurement is inappropriate because the calcium elevation should be evaluated, but repeating it alone does not address the likely systemic diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            },
            {
              "id": "B",
              "text": "Option B: Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "C",
              "text": "Option D: Repeat serum calcium measurement is inappropriate because the calcium elevation should be evaluated, but repeating it alone does not address the likely systemic diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat serum calcium measurement is inappropriate because the calcium elevation should be evaluated, but repeating it alone does not address the likely systemic diagnosis."
            },
            {
              "id": "B",
              "text": "Option B: Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat serum calcium measurement is inappropriate because the calcium elevation should be evaluated, but repeating it alone does not address the likely systemic diagnosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum protein electrophoresis is used when plasma cell dyscrasia is suspected, which is not suggested here."
            },
            {
              "id": "B",
              "text": "Option B: Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum protein electrophoresis is used when plasma cell dyscrasia is suspected, which is not suggested here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure the serum angiotensin-converting enzyme concentration is inappropriate because serum ACE has insufficient sensitivity and specificity to establish sarcoidosis. Chest radiography directly evaluates the expected bilateral hilar lymphadenopathy and pulmonary involvement."
            },
            {
              "id": "B",
              "text": "Option B: Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure the serum angiotensin-converting enzyme concentration is inappropriate because serum ACE has insufficient sensitivity and specificity to establish sarcoidosis. Chest radiography directly evaluates the expected bilateral hilar lymphadenopathy and pulmonary involvement."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Biopsy an erythematous shin nodule is inappropriate because erythema nodosum is a nonspecific septal panniculitis and biopsy generally does not demonstrate the diagnostic noncaseating granulomas. The classic clinical pattern should first prompt chest imaging."
            },
            {
              "id": "B",
              "text": "Option B: Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Biopsy an erythematous shin nodule is inappropriate because erythema nodosum is a nonspecific septal panniculitis and biopsy generally does not demonstrate the diagnostic noncaseating granulomas. The classic clinical pattern should first prompt chest imaging."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an interferon-gamma release assay for tuberculosis is inappropriate because tuberculosis belongs in the granulomatous differential, but isolated testing for TB does not best evaluate the classic combination of erythema nodosum, bilateral ankle inflammation, dyspnea, and hypercalcemia."
            },
            {
              "id": "B",
              "text": "Option B: Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an interferon-gamma release assay for tuberculosis is inappropriate because tuberculosis belongs in the granulomatous differential, but isolated testing for TB does not best evaluate the classic combination of erythema nodosum, bilateral ankle inflammation, dyspnea, and hypercalcemia."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform diagnostic ankle arthrocentesis is inappropriate because the bilateral subacute ankle inflammation accompanying erythema nodosum is characteristic of L\u00F6fgren syndrome. Arthrocentesis is unnecessary without an acute monoarthritis or concern for septic or crystal arthritis."
            },
            {
              "id": "B",
              "text": "Option B: Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform diagnostic ankle arthrocentesis is inappropriate because the bilateral subacute ankle inflammation accompanying erythema nodosum is characteristic of L\u00F6fgren syndrome. Arthrocentesis is unnecessary without an acute monoarthritis or concern for septic or crystal arthritis."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain pulmonary function testing is inappropriate because pulmonary function tests can characterize functional impairment after pulmonary sarcoidosis is identified, but they do not provide the expected diagnostic finding of bilateral hilar adenopathy."
            },
            {
              "id": "B",
              "text": "Option B: Antinuclear antibody testing is inappropriate because antinuclear antibodies are not the best initial test for this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum parathyroid hormone measurement is inappropriate because parathyroid hormone testing evaluates hypercalcemia but does not best unify the pulmonary and inflammatory skin-joint findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain pulmonary function testing is inappropriate because pulmonary function tests can characterize functional impairment after pulmonary sarcoidosis is identified, but they do not provide the expected diagnostic finding of bilateral hilar adenopathy."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i029-guaiac-vitamin-c-interference",
      "expectedHashes": {
        "ranaze_step3_uat": "1e95f43e94853c9cbd4f47ac9234a4f041790f63b76f6b5bb784f1c65f1523da",
        "ranaze_step3_prd": "1e95f43e94853c9cbd4f47ac9234a4f041790f63b76f6b5bb784f1c65f1523da"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Daily low-dose aspirin use is inappropriate because aspirin can increase gastrointestinal bleeding and is more likely to contribute to a false-positive rather than a false-negative result."
            },
            {
              "id": "B",
              "text": "Option C: Frequent calcium carbonate use is inappropriate because calcium carbonate does not inhibit the guaiac detection reaction."
            },
            {
              "id": "C",
              "text": "Option D: Oral ferrous sulfate use is inappropriate because oral iron can darken stool but does not cause a false-negative guaiac reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Daily low-dose aspirin use is inappropriate because aspirin can increase gastrointestinal bleeding and is more likely to contribute to a false-positive rather than a false-negative result."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Frequent calcium carbonate use is inappropriate because calcium carbonate does not inhibit the guaiac detection reaction."
            },
            {
              "id": "B",
              "text": "Option B: Daily low-dose aspirin use is inappropriate because aspirin can increase gastrointestinal bleeding and is more likely to contribute to a false-positive rather than a false-negative result."
            },
            {
              "id": "C",
              "text": "Option D: Oral ferrous sulfate use is inappropriate because oral iron can darken stool but does not cause a false-negative guaiac reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Frequent calcium carbonate use is inappropriate because calcium carbonate does not inhibit the guaiac detection reaction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral ferrous sulfate use is inappropriate because oral iron can darken stool but does not cause a false-negative guaiac reaction."
            },
            {
              "id": "B",
              "text": "Option B: Daily low-dose aspirin use is inappropriate because aspirin can increase gastrointestinal bleeding and is more likely to contribute to a false-positive rather than a false-negative result."
            },
            {
              "id": "C",
              "text": "Option C: Frequent calcium carbonate use is inappropriate because calcium carbonate does not inhibit the guaiac detection reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral ferrous sulfate use is inappropriate because oral iron can darken stool but does not cause a false-negative guaiac reaction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduced dietary carbohydrate intake is inappropriate because carbohydrate restriction does not interfere with guaiac testing."
            },
            {
              "id": "B",
              "text": "Option B: Daily low-dose aspirin use is inappropriate because aspirin can increase gastrointestinal bleeding and is more likely to contribute to a false-positive rather than a false-negative result."
            },
            {
              "id": "C",
              "text": "Option C: Frequent calcium carbonate use is inappropriate because calcium carbonate does not inhibit the guaiac detection reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduced dietary carbohydrate intake is inappropriate because carbohydrate restriction does not interfere with guaiac testing."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i031-suspected-pulmonary-tuberculosis-isolation",
      "expectedHashes": {
        "ranaze_step3_uat": "96abe9645cd7116506a8a5d2361f9cbfbcf6df3d3c9a267ee9d4733472f6c95b",
        "ranaze_step3_prd": "96abe9645cd7116506a8a5d2361f9cbfbcf6df3d3c9a267ee9d4733472f6c95b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
            },
            {
              "id": "B",
              "text": "Option B: Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
            },
            {
              "id": "C",
              "text": "Option C: Arrange comfort-focused hospice care is inappropriate because the presentation requires urgent infection-control measures and evaluation for a treatable communicable disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
            },
            {
              "id": "B",
              "text": "Option A: Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
            },
            {
              "id": "C",
              "text": "Option C: Arrange comfort-focused hospice care is inappropriate because the presentation requires urgent infection-control measures and evaluation for a treatable communicable disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange comfort-focused hospice care is inappropriate because the presentation requires urgent infection-control measures and evaluation for a treatable communicable disease."
            },
            {
              "id": "B",
              "text": "Option A: Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
            },
            {
              "id": "C",
              "text": "Option B: Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange comfort-focused hospice care is inappropriate because the presentation requires urgent infection-control measures and evaluation for a treatable communicable disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly to thoracic surgery is inappropriate because thoracic surgery is not the initial step in a stable patient with suspected infectious cavitary lung disease."
            },
            {
              "id": "B",
              "text": "Option A: Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
            },
            {
              "id": "C",
              "text": "Option B: Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly to thoracic surgery is inappropriate because thoracic surgery is not the initial step in a stable patient with suspected infectious cavitary lung disease."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform diagnostic bronchoscopy immediately is inappropriate because bronchoscopy is an aerosol-generating procedure and is not the first step in a stable patient who can undergo sputum evaluation. It must not precede airborne infection-control measures."
            },
            {
              "id": "B",
              "text": "Option A: Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
            },
            {
              "id": "C",
              "text": "Option B: Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform diagnostic bronchoscopy immediately is inappropriate because bronchoscopy is an aerosol-generating procedure and is not the first step in a stable patient who can undergo sputum evaluation. It must not precede airborne infection-control measures."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place the patient under droplet precautions is inappropriate because pulmonary tuberculosis is transmitted by airborne droplet nuclei and requires airborne precautions in an airborne infection isolation room, not droplet precautions alone."
            },
            {
              "id": "B",
              "text": "Option A: Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
            },
            {
              "id": "C",
              "text": "Option B: Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place the patient under droplet precautions is inappropriate because pulmonary tuberculosis is transmitted by airborne droplet nuclei and requires airborne precautions in an airborne infection isolation room, not droplet precautions alone."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain contrast-enhanced CT of the chest to characterize the cavity is inappropriate because cT may subsequently define the cavity or bleeding source, but the radiograph and clinical presentation already create sufficient suspicion for infectious pulmonary tuberculosis to require immediate airborne isolation."
            },
            {
              "id": "B",
              "text": "Option A: Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
            },
            {
              "id": "C",
              "text": "Option B: Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain contrast-enhanced CT of the chest to characterize the cavity is inappropriate because cT may subsequently define the cavity or bleeding source, but the radiograph and clinical presentation already create sufficient suspicion for infectious pulmonary tuberculosis to require immediate airborne isolation."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain sputum for acid-fast bacillus smear, mycobacterial culture, and nucleic acid amplification testing is inappropriate because sputum smear, culture, and nucleic acid amplification testing are indicated in suspected pulmonary tuberculosis. However, this patient\u0027s cough, constitutional symptoms, congregate residence, and upper-lobe cavitary infiltrate create an immediate risk of airborne transmission. Airborne infection isolation is therefore the most appropriate next step; sputum should subsequently be collected under appropriate airborne controls."
            },
            {
              "id": "B",
              "text": "Option A: Begin systemic corticosteroid therapy is inappropriate because corticosteroids are not the initial intervention for suspected cavitary pulmonary tuberculosis."
            },
            {
              "id": "C",
              "text": "Option B: Initiate noninvasive positive-pressure ventilation is inappropriate because noninvasive ventilation is not indicated because oxygenation and respiratory rate are currently adequate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain sputum for acid-fast bacillus smear, mycobacterial culture, and nucleic acid amplification testing is inappropriate because sputum smear, culture, and nucleic acid amplification testing are indicated in suspected pulmonary tuberculosis. However, this patient\u0027s cough, constitutional symptoms, congregate residence, and upper-lobe cavitary infiltrate create an immediate risk of airborne transmission. Airborne infection isolation is therefore the most appropriate next step; sputum should subsequently be collected under appropriate airborne controls."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i033-pneumocystis-treatment-sulfa-allergy",
      "expectedHashes": {
        "ranaze_step3_uat": "e9e5b4b7e6013bf5d1bedfa9a7bec53b77eb6e5e283c1d3fab7fd2d323afd4cd",
        "ranaze_step3_prd": "e9e5b4b7e6013bf5d1bedfa9a7bec53b77eb6e5e283c1d3fab7fd2d323afd4cd"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            },
            {
              "id": "C",
              "text": "Option D: Isoniazid-based therapy is inappropriate because isoniazid is used for tuberculosis treatment or prophylaxis and would not treat this presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option D: Isoniazid-based therapy is inappropriate because isoniazid is used for tuberculosis treatment or prophylaxis and would not treat this presentation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isoniazid-based therapy is inappropriate because isoniazid is used for tuberculosis treatment or prophylaxis and would not treat this presentation."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isoniazid-based therapy is inappropriate because isoniazid is used for tuberculosis treatment or prophylaxis and would not treat this presentation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral atovaquone is inappropriate because atovaquone is an alternative for mild-to-moderate Pneumocystis pneumonia; this degree of hypoxemia requires treatment for severe disease."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral atovaquone is inappropriate because atovaquone is an alternative for mild-to-moderate Pneumocystis pneumonia; this degree of hypoxemia requires treatment for severe disease."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous trimethoprim-sulfamethoxazole with antihistamine premedication is inappropriate because tMP-SMX is first-line PCP therapy, but antihistamine premedication does not prevent recurrent anaphylaxis. A life-threatening prior reaction requires permanent avoidance rather than immediate rechallenge."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous trimethoprim-sulfamethoxazole with antihistamine premedication is inappropriate because tMP-SMX is first-line PCP therapy, but antihistamine premedication does not prevent recurrent anaphylaxis. A life-threatening prior reaction requires permanent avoidance rather than immediate rechallenge."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral trimethoprim plus dapsone is inappropriate because this regimen is inappropriate because it re-exposes the patient to dapsone after documented anaphylaxis and is an option only for mild-to-moderate PCP, not marked hypoxemia."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral trimethoprim plus dapsone is inappropriate because this regimen is inappropriate because it re-exposes the patient to dapsone after documented anaphylaxis and is an option only for mild-to-moderate PCP, not marked hypoxemia."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aerosolized pentamidine is used primarily for prophylaxis and provides less reliable treatment of pulmonary disease than systemic pentamidine. Severe PCP requires daily intravenous therapy."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aerosolized pentamidine is used primarily for prophylaxis and provides less reliable treatment of pulmonary disease than systemic pentamidine. Severe PCP requires daily intravenous therapy."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Systemic corticosteroids without antipneumocystis therapy is inappropriate because corticosteroids are appropriate adjunctive therapy in moderate-to-severe PCP but have no activity against Pneumocystis and cannot replace antipneumocystis treatment."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Systemic corticosteroids without antipneumocystis therapy is inappropriate because corticosteroids are appropriate adjunctive therapy in moderate-to-severe PCP but have no activity against Pneumocystis and cannot replace antipneumocystis treatment."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate antiretroviral therapy as the sole treatment is inappropriate because antiretroviral therapy should generally be initiated within 2 weeks of PCP diagnosis, but it does not treat the acute opportunistic infection and cannot replace immediate antipneumocystis therapy."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate antiretroviral therapy as the sole treatment is inappropriate because antiretroviral therapy should generally be initiated within 2 weeks of PCP diagnosis, but it does not treat the acute opportunistic infection and cannot replace immediate antipneumocystis therapy."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bronchoscopy with bronchoalveolar lavage before initiating treatment is inappropriate because microbiologic confirmation may be pursued when needed, but treatment should not be delayed in a severely hypoxemic child with a classic presentation. Immediate stabilization and antipneumocystis therapy are required."
            },
            {
              "id": "B",
              "text": "Option A: Intravenous ceftriaxone is inappropriate because ceftriaxone treats common bacterial pneumonia but does not treat Pneumocystis jirovecii pneumonia."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous ganciclovir is inappropriate because ganciclovir is used for cytomegalovirus disease, not the most likely cause of this subacute hypoxemic interstitial pneumonia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bronchoscopy with bronchoalveolar lavage before initiating treatment is inappropriate because microbiologic confirmation may be pursued when needed, but treatment should not be delayed in a severely hypoxemic child with a classic presentation. Immediate stabilization and antipneumocystis therapy are required."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i034-obesity-lifestyle-assessment",
      "expectedHashes": {
        "ranaze_step3_uat": "543dcfc56218f3591be8c6c2d3aec62909c7b091a24d1ccd8f15a45cefddcd93",
        "ranaze_step3_prd": "543dcfc56218f3591be8c6c2d3aec62909c7b091a24d1ccd8f15a45cefddcd93"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure waist-to-hip ratio is inappropriate because waist-to-hip ratio can estimate central adiposity but does not provide the needed initial assessment of modifiable behaviors."
            },
            {
              "id": "B",
              "text": "Option C: Obtain a serum thyroid-stimulating hormone concentration is inappropriate because hypothyroidism testing is not the initial priority in a patient without symptoms suggesting hypothyroidism."
            },
            {
              "id": "C",
              "text": "Option D: Start weight-loss medication immediately is inappropriate because weight-loss medication may be considered later, but it should be paired with lifestyle intervention rather than used before behavioral assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure waist-to-hip ratio is inappropriate because waist-to-hip ratio can estimate central adiposity but does not provide the needed initial assessment of modifiable behaviors."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a serum thyroid-stimulating hormone concentration is inappropriate because hypothyroidism testing is not the initial priority in a patient without symptoms suggesting hypothyroidism."
            },
            {
              "id": "B",
              "text": "Option A: Measure waist-to-hip ratio is inappropriate because waist-to-hip ratio can estimate central adiposity but does not provide the needed initial assessment of modifiable behaviors."
            },
            {
              "id": "C",
              "text": "Option D: Start weight-loss medication immediately is inappropriate because weight-loss medication may be considered later, but it should be paired with lifestyle intervention rather than used before behavioral assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a serum thyroid-stimulating hormone concentration is inappropriate because hypothyroidism testing is not the initial priority in a patient without symptoms suggesting hypothyroidism."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start weight-loss medication immediately is inappropriate because weight-loss medication may be considered later, but it should be paired with lifestyle intervention rather than used before behavioral assessment."
            },
            {
              "id": "B",
              "text": "Option A: Measure waist-to-hip ratio is inappropriate because waist-to-hip ratio can estimate central adiposity but does not provide the needed initial assessment of modifiable behaviors."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a serum thyroid-stimulating hormone concentration is inappropriate because hypothyroidism testing is not the initial priority in a patient without symptoms suggesting hypothyroidism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start weight-loss medication immediately is inappropriate because weight-loss medication may be considered later, but it should be paired with lifestyle intervention rather than used before behavioral assessment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order an oral glucose tolerance test is inappropriate because glucose screening may be appropriate based on overall cardiometabolic risk, but it does not address the first management step."
            },
            {
              "id": "B",
              "text": "Option A: Measure waist-to-hip ratio is inappropriate because waist-to-hip ratio can estimate central adiposity but does not provide the needed initial assessment of modifiable behaviors."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a serum thyroid-stimulating hormone concentration is inappropriate because hypothyroidism testing is not the initial priority in a patient without symptoms suggesting hypothyroidism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order an oral glucose tolerance test is inappropriate because glucose screening may be appropriate based on overall cardiometabolic risk, but it does not address the first management step."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe a very-low-calorie diet without further assessment is inappropriate because a very-low-calorie diet requires careful selection and medical supervision and should not be prescribed before evaluating the patient\u0027s behaviors, nutritional intake, readiness, and sustainable treatment options."
            },
            {
              "id": "B",
              "text": "Option A: Measure waist-to-hip ratio is inappropriate because waist-to-hip ratio can estimate central adiposity but does not provide the needed initial assessment of modifiable behaviors."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a serum thyroid-stimulating hormone concentration is inappropriate because hypothyroidism testing is not the initial priority in a patient without symptoms suggesting hypothyroidism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe a very-low-calorie diet without further assessment is inappropriate because a very-low-calorie diet requires careful selection and medical supervision and should not be prescribed before evaluating the patient\u0027s behaviors, nutritional intake, readiness, and sustainable treatment options."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure a fasting serum insulin concentration is inappropriate because fasting insulin is not needed to diagnose obesity or guide its initial management. His BMI already establishes obesity, and the first task is behavioral assessment and planning."
            },
            {
              "id": "B",
              "text": "Option A: Measure waist-to-hip ratio is inappropriate because waist-to-hip ratio can estimate central adiposity but does not provide the needed initial assessment of modifiable behaviors."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a serum thyroid-stimulating hormone concentration is inappropriate because hypothyroidism testing is not the initial priority in a patient without symptoms suggesting hypothyroidism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure a fasting serum insulin concentration is inappropriate because fasting insulin is not needed to diagnose obesity or guide its initial management. His BMI already establishes obesity, and the first task is behavioral assessment and planning."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain exercise stress testing before recommending physical activity is inappropriate because routine exercise stress testing is not required before initiating ordinary physical activity in an asymptomatic patient with a normal examination. The appropriate first step is to assess current activity and develop an individualized plan."
            },
            {
              "id": "B",
              "text": "Option A: Measure waist-to-hip ratio is inappropriate because waist-to-hip ratio can estimate central adiposity but does not provide the needed initial assessment of modifiable behaviors."
            },
            {
              "id": "C",
              "text": "Option C: Obtain a serum thyroid-stimulating hormone concentration is inappropriate because hypothyroidism testing is not the initial priority in a patient without symptoms suggesting hypothyroidism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain exercise stress testing before recommending physical activity is inappropriate because routine exercise stress testing is not required before initiating ordinary physical activity in an asymptomatic patient with a normal examination. The appropriate first step is to assess current activity and develop an individualized plan."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i035-diabetic-autonomic-peripheral-neuropathy",
      "expectedHashes": {
        "ranaze_step3_uat": "60971518dcc35c4dfd5f5ce77e1a1b19d54d581574d7d979973894b6da161d18",
        "ranaze_step3_prd": "60971518dcc35c4dfd5f5ce77e1a1b19d54d581574d7d979973894b6da161d18"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Impaired short-term memory is inappropriate because normal mental status and the pattern of autonomic symptoms do not suggest a dementing disorder."
            },
            {
              "id": "B",
              "text": "Option C: Dysmetria on finger-to-nose testing is inappropriate because dysmetria suggests cerebellar dysfunction rather than diabetic peripheral or autonomic neuropathy."
            },
            {
              "id": "C",
              "text": "Option D: Spastic lower-extremity weakness with hyperreflexia is inappropriate because spasticity and hyperreflexia indicate an upper motor neuron disorder, not diabetic polyneuropathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Impaired short-term memory is inappropriate because normal mental status and the pattern of autonomic symptoms do not suggest a dementing disorder."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dysmetria on finger-to-nose testing is inappropriate because dysmetria suggests cerebellar dysfunction rather than diabetic peripheral or autonomic neuropathy."
            },
            {
              "id": "B",
              "text": "Option A: Impaired short-term memory is inappropriate because normal mental status and the pattern of autonomic symptoms do not suggest a dementing disorder."
            },
            {
              "id": "C",
              "text": "Option D: Spastic lower-extremity weakness with hyperreflexia is inappropriate because spasticity and hyperreflexia indicate an upper motor neuron disorder, not diabetic polyneuropathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dysmetria on finger-to-nose testing is inappropriate because dysmetria suggests cerebellar dysfunction rather than diabetic peripheral or autonomic neuropathy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Spastic lower-extremity weakness with hyperreflexia is inappropriate because spasticity and hyperreflexia indicate an upper motor neuron disorder, not diabetic polyneuropathy."
            },
            {
              "id": "B",
              "text": "Option A: Impaired short-term memory is inappropriate because normal mental status and the pattern of autonomic symptoms do not suggest a dementing disorder."
            },
            {
              "id": "C",
              "text": "Option C: Dysmetria on finger-to-nose testing is inappropriate because dysmetria suggests cerebellar dysfunction rather than diabetic peripheral or autonomic neuropathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Spastic lower-extremity weakness with hyperreflexia is inappropriate because spasticity and hyperreflexia indicate an upper motor neuron disorder, not diabetic polyneuropathy."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A resting pill-rolling tremor is inappropriate because a resting tremor suggests parkinsonism and is not expected from diabetic neuropathy."
            },
            {
              "id": "B",
              "text": "Option A: Impaired short-term memory is inappropriate because normal mental status and the pattern of autonomic symptoms do not suggest a dementing disorder."
            },
            {
              "id": "C",
              "text": "Option C: Dysmetria on finger-to-nose testing is inappropriate because dysmetria suggests cerebellar dysfunction rather than diabetic peripheral or autonomic neuropathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A resting pill-rolling tremor is inappropriate because a resting tremor suggests parkinsonism and is not expected from diabetic neuropathy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hyperpigmentation of the palmar creases is inappropriate because palmar-crease hyperpigmentation suggests primary adrenal insufficiency. That disorder can cause hypotension and gastrointestinal symptoms, but it does not explain this patient\u0027s long-standing diabetes with retinopathy, nephropathy, bladder dysfunction, and marked autonomic orthostasis; her supine blood pressure is hypertensive."
            },
            {
              "id": "B",
              "text": "Option A: Impaired short-term memory is inappropriate because normal mental status and the pattern of autonomic symptoms do not suggest a dementing disorder."
            },
            {
              "id": "C",
              "text": "Option C: Dysmetria on finger-to-nose testing is inappropriate because dysmetria suggests cerebellar dysfunction rather than diabetic peripheral or autonomic neuropathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hyperpigmentation of the palmar creases is inappropriate because palmar-crease hyperpigmentation suggests primary adrenal insufficiency. That disorder can cause hypotension and gastrointestinal symptoms, but it does not explain this patient\u0027s long-standing diabetes with retinopathy, nephropathy, bladder dysfunction, and marked autonomic orthostasis; her supine blood pressure is hypertensive."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Symmetric proximal hip-girdle weakness is inappropriate because symmetric proximal weakness would suggest a myopathy or diabetic lumbosacral radiculoplexus neuropathy rather than the common distal symmetric polyneuropathy associated with diabetic autonomic neuropathy. The stem explicitly states that muscle strength is normal."
            },
            {
              "id": "B",
              "text": "Option A: Impaired short-term memory is inappropriate because normal mental status and the pattern of autonomic symptoms do not suggest a dementing disorder."
            },
            {
              "id": "C",
              "text": "Option C: Dysmetria on finger-to-nose testing is inappropriate because dysmetria suggests cerebellar dysfunction rather than diabetic peripheral or autonomic neuropathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Symmetric proximal hip-girdle weakness is inappropriate because symmetric proximal weakness would suggest a myopathy or diabetic lumbosacral radiculoplexus neuropathy rather than the common distal symmetric polyneuropathy associated with diabetic autonomic neuropathy. The stem explicitly states that muscle strength is normal."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decreased perianal sensation with reduced anal sphincter tone is inappropriate because perianal sensory loss and reduced sphincter tone would localize to the sacral roots or cauda equina. The distributed gastrointestinal, bladder, and cardiovascular symptoms instead indicate generalized diabetic autonomic neuropathy."
            },
            {
              "id": "B",
              "text": "Option A: Impaired short-term memory is inappropriate because normal mental status and the pattern of autonomic symptoms do not suggest a dementing disorder."
            },
            {
              "id": "C",
              "text": "Option C: Dysmetria on finger-to-nose testing is inappropriate because dysmetria suggests cerebellar dysfunction rather than diabetic peripheral or autonomic neuropathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decreased perianal sensation with reduced anal sphincter tone is inappropriate because perianal sensory loss and reduced sphincter tone would localize to the sacral roots or cauda equina. The distributed gastrointestinal, bladder, and cardiovascular symptoms instead indicate generalized diabetic autonomic neuropathy."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i038-preoperative-fev1",
      "expectedHashes": {
        "ranaze_step3_uat": "e7fc0e521b770f8de51a3f0ce9c5ddb1f215b8b2f3758d23eefe121e99bde6bf",
        "ranaze_step3_prd": "e7fc0e521b770f8de51a3f0ce9c5ddb1f215b8b2f3758d23eefe121e99bde6bf"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alveolar-arterial oxygen gradient is inappropriate because the alveolar-arterial gradient does not quantify ventilatory reserve for resection."
            },
            {
              "id": "B",
              "text": "Option C: Resting arterial carbon dioxide tension is inappropriate because resting carbon dioxide tension may reflect severe ventilatory failure but does not best predict postoperative pulmonary reserve."
            },
            {
              "id": "C",
              "text": "Option D: Resting arterial oxygen tension is inappropriate because normal resting oxygenation does not exclude inadequate reserve after lung resection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alveolar-arterial oxygen gradient is inappropriate because the alveolar-arterial gradient does not quantify ventilatory reserve for resection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Resting arterial carbon dioxide tension is inappropriate because resting carbon dioxide tension may reflect severe ventilatory failure but does not best predict postoperative pulmonary reserve."
            },
            {
              "id": "B",
              "text": "Option A: Alveolar-arterial oxygen gradient is inappropriate because the alveolar-arterial gradient does not quantify ventilatory reserve for resection."
            },
            {
              "id": "C",
              "text": "Option D: Resting arterial oxygen tension is inappropriate because normal resting oxygenation does not exclude inadequate reserve after lung resection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Resting arterial carbon dioxide tension is inappropriate because resting carbon dioxide tension may reflect severe ventilatory failure but does not best predict postoperative pulmonary reserve."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Resting arterial oxygen tension is inappropriate because normal resting oxygenation does not exclude inadequate reserve after lung resection."
            },
            {
              "id": "B",
              "text": "Option A: Alveolar-arterial oxygen gradient is inappropriate because the alveolar-arterial gradient does not quantify ventilatory reserve for resection."
            },
            {
              "id": "C",
              "text": "Option C: Resting arterial carbon dioxide tension is inappropriate because resting carbon dioxide tension may reflect severe ventilatory failure but does not best predict postoperative pulmonary reserve."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Resting arterial oxygen tension is inappropriate because normal resting oxygenation does not exclude inadequate reserve after lung resection."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vital capacity is less useful than FEV1 for assessing obstructive disease and operative pulmonary risk."
            },
            {
              "id": "B",
              "text": "Option A: Alveolar-arterial oxygen gradient is inappropriate because the alveolar-arterial gradient does not quantify ventilatory reserve for resection."
            },
            {
              "id": "C",
              "text": "Option C: Resting arterial carbon dioxide tension is inappropriate because resting carbon dioxide tension may reflect severe ventilatory failure but does not best predict postoperative pulmonary reserve."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vital capacity is less useful than FEV1 for assessing obstructive disease and operative pulmonary risk."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stair-climbing exercise test is inappropriate because stair climbing is a low-technology exercise screen used after spirometry and DLCO identify intermediate risk, not before pulmonary function is measured."
            },
            {
              "id": "B",
              "text": "Option A: Alveolar-arterial oxygen gradient is inappropriate because the alveolar-arterial gradient does not quantify ventilatory reserve for resection."
            },
            {
              "id": "C",
              "text": "Option C: Resting arterial carbon dioxide tension is inappropriate because resting carbon dioxide tension may reflect severe ventilatory failure but does not best predict postoperative pulmonary reserve."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stair-climbing exercise test is inappropriate because stair climbing is a low-technology exercise screen used after spirometry and DLCO identify intermediate risk, not before pulmonary function is measured."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Six-minute walk distance is inappropriate because although walking capacity reflects functional status, the six-minute walk is not the recommended initial measurement for estimating pulmonary reserve after lung resection."
            },
            {
              "id": "B",
              "text": "Option A: Alveolar-arterial oxygen gradient is inappropriate because the alveolar-arterial gradient does not quantify ventilatory reserve for resection."
            },
            {
              "id": "C",
              "text": "Option C: Resting arterial carbon dioxide tension is inappropriate because resting carbon dioxide tension may reflect severe ventilatory failure but does not best predict postoperative pulmonary reserve."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Six-minute walk distance is inappropriate because although walking capacity reflects functional status, the six-minute walk is not the recommended initial measurement for estimating pulmonary reserve after lung resection."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maximal voluntary ventilation is effort dependent and is not preferred over FEV1 with a predicted postoperative calculation for contemporary resection-risk assessment."
            },
            {
              "id": "B",
              "text": "Option A: Alveolar-arterial oxygen gradient is inappropriate because the alveolar-arterial gradient does not quantify ventilatory reserve for resection."
            },
            {
              "id": "C",
              "text": "Option C: Resting arterial carbon dioxide tension is inappropriate because resting carbon dioxide tension may reflect severe ventilatory failure but does not best predict postoperative pulmonary reserve."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maximal voluntary ventilation is effort dependent and is not preferred over FEV1 with a predicted postoperative calculation for contemporary resection-risk assessment."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i041-placental-abruption-fetal-distress",
      "expectedHashes": {
        "ranaze_step3_uat": "d395449576ee6f6cbdf51fb771ac24ddcbd583b8e6a4279f34750c31a29d7cc3",
        "ranaze_step3_prd": "d395449576ee6f6cbdf51fb771ac24ddcbd583b8e6a4279f34750c31a29d7cc3"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "B",
              "text": "Option B: Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            },
            {
              "id": "C",
              "text": "Option D: Observe until maternal blood type and crossmatch results return is inappropriate because blood products should be prepared concurrently, but waiting would delay urgent delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            },
            {
              "id": "B",
              "text": "Option A: Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "C",
              "text": "Option D: Observe until maternal blood type and crossmatch results return is inappropriate because blood products should be prepared concurrently, but waiting would delay urgent delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe until maternal blood type and crossmatch results return is inappropriate because blood products should be prepared concurrently, but waiting would delay urgent delivery."
            },
            {
              "id": "B",
              "text": "Option A: Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe until maternal blood type and crossmatch results return is inappropriate because blood products should be prepared concurrently, but waiting would delay urgent delivery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange interfacility transfer to a tertiary neonatal center is inappropriate because transfer is unsafe when immediate delivery is required for fetal compromise."
            },
            {
              "id": "B",
              "text": "Option A: Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange interfacility transfer to a tertiary neonatal center is inappropriate because transfer is unsafe when immediate delivery is required for fetal compromise."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin induction of labor with oxytocin is inappropriate because oxytocin induction would delay delivery in a patient with suspected major placental abruption and persistent fetal bradycardia. Immediate cesarean delivery is required when vaginal birth is not imminent."
            },
            {
              "id": "B",
              "text": "Option A: Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin induction of labor with oxytocin is inappropriate because oxytocin induction would delay delivery in a patient with suspected major placental abruption and persistent fetal bradycardia. Immediate cesarean delivery is required when vaginal birth is not imminent."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Attempt operative vaginal delivery is inappropriate because operative vaginal delivery requires an engaged, sufficiently descended fetal head and complete cervical dilation. The presenting part is explicitly not engaged."
            },
            {
              "id": "B",
              "text": "Option A: Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Attempt operative vaginal delivery is inappropriate because operative vaginal delivery requires an engaged, sufficiently descended fetal head and complete cervical dilation. The presenting part is explicitly not engaged."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer antenatal betamethasone and delay delivery for 48 hours is inappropriate because antenatal corticosteroids may benefit selected pregnancies at risk of preterm birth, but treatment must not delay an indicated emergency delivery. Persistent fetal bradycardia represents an immediate threat."
            },
            {
              "id": "B",
              "text": "Option A: Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer antenatal betamethasone and delay delivery for 48 hours is inappropriate because antenatal corticosteroids may benefit selected pregnancies at risk of preterm birth, but treatment must not delay an indicated emergency delivery. Persistent fetal bradycardia represents an immediate threat."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform amniotomy to expedite vaginal delivery is inappropriate because amniotomy does not provide sufficiently rapid delivery here and, with an unengaged presenting part, may precipitate umbilical cord prolapse. It must not delay emergency cesarean delivery for fetal bradycardia."
            },
            {
              "id": "B",
              "text": "Option A: Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform amniotomy to expedite vaginal delivery is inappropriate because amniotomy does not provide sufficiently rapid delivery here and, with an unengaged presenting part, may precipitate umbilical cord prolapse. It must not delay emergency cesarean delivery for fetal bradycardia."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer maternal supplemental oxygen and reassess the fetal heart rate is inappropriate because maternal oxygen is not definitive treatment for placental separation and must not be used to postpone delivery. Persistent fetal bradycardia requires immediate expedited birth."
            },
            {
              "id": "B",
              "text": "Option A: Administer a tocolytic medication is inappropriate because tocolysis is inappropriate with suspected placental abruption and fetal compromise."
            },
            {
              "id": "C",
              "text": "Option B: Obtain a formal obstetric ultrasonogram is inappropriate because ultrasonography can miss placental abruption and must not delay delivery for fetal bradycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer maternal supplemental oxygen and reassess the fetal heart rate is inappropriate because maternal oxygen is not definitive treatment for placental separation and must not be used to postpone delivery. Persistent fetal bradycardia requires immediate expedited birth."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i042-asymptomatic-uterine-leiomyoma",
      "expectedHashes": {
        "ranaze_step3_uat": "2cfffefcec738c6ecd2275a5079eaba7c60e1a6e0eeb33b1a7450c44320e471e",
        "ranaze_step3_prd": "2cfffefcec738c6ecd2275a5079eaba7c60e1a6e0eeb33b1a7450c44320e471e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
            },
            {
              "id": "B",
              "text": "Option B: Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
            },
            {
              "id": "C",
              "text": "Option C: Pelvic magnetic resonance imaging is inappropriate because additional imaging is unnecessary for stable, clinically apparent, asymptomatic fibroids."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option C: Pelvic magnetic resonance imaging is inappropriate because additional imaging is unnecessary for stable, clinically apparent, asymptomatic fibroids."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pelvic magnetic resonance imaging is inappropriate because additional imaging is unnecessary for stable, clinically apparent, asymptomatic fibroids."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option B: Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pelvic magnetic resonance imaging is inappropriate because additional imaging is unnecessary for stable, clinically apparent, asymptomatic fibroids."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Uterine artery embolization is a treatment option for symptomatic fibroids."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option B: Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Uterine artery embolization is a treatment option for symptomatic fibroids."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a transvaginal pelvic ultrasonogram is inappropriate because imaging is unnecessary when the examination is consistent with fibroids, uterine size has remained stable for 18 months, and there are no symptoms or new pelvic findings."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option B: Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a transvaginal pelvic ultrasonogram is inappropriate because imaging is unnecessary when the examination is consistent with fibroids, uterine size has remained stable for 18 months, and there are no symptoms or new pelvic findings."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a total hysterectomy is inappropriate because hysterectomy is definitive but invasive treatment for clinically significant fibroid symptoms or other uterine disease. Stable asymptomatic fibroids require no procedure."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option B: Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a total hysterectomy is inappropriate because hysterectomy is definitive but invasive treatment for clinically significant fibroid symptoms or other uterine disease. Stable asymptomatic fibroids require no procedure."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin combined oral contraceptive therapy is inappropriate because combined hormonal contraceptives can reduce fibroid-associated heavy menstrual bleeding but do not treat an asymptomatic, stable uterine enlargement. She has predictable periods without heavy or intermenstrual bleeding."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option B: Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin combined oral contraceptive therapy is inappropriate because combined hormonal contraceptives can reduce fibroid-associated heavy menstrual bleeding but do not treat an asymptomatic, stable uterine enlargement. She has predictable periods without heavy or intermenstrual bleeding."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin tranexamic acid during each menstrual period is inappropriate because tranexamic acid treats heavy menstrual bleeding; the patient explicitly denies heavy flow."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial biopsy is indicated for abnormal uterine bleeding or other concern for endometrial pathology, neither of which is present."
            },
            {
              "id": "C",
              "text": "Option B: Gonadotropin-releasing hormone agonist therapy is inappropriate because gnRH agonists are used temporarily for symptomatic fibroids or preoperative reduction in fibroid size."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin tranexamic acid during each menstrual period is inappropriate because tranexamic acid treats heavy menstrual bleeding; the patient explicitly denies heavy flow."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i043-spondylolysis-return-to-sport",
      "expectedHashes": {
        "ranaze_step3_uat": "be9c62d29f3b9dcb04f3666797b866810ec0b37e961462b52303e34e46bdab6e",
        "ranaze_step3_prd": "be9c62d29f3b9dcb04f3666797b866810ec0b37e961462b52303e34e46bdab6e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
            },
            {
              "id": "B",
              "text": "Option B: Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
            },
            {
              "id": "C",
              "text": "Option D: Stop all athletic activity until skeletal maturity is complete is inappropriate because long-term restriction through skeletal maturity is not routinely necessary."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
            },
            {
              "id": "B",
              "text": "Option A: Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
            },
            {
              "id": "C",
              "text": "Option D: Stop all athletic activity until skeletal maturity is complete is inappropriate because long-term restriction through skeletal maturity is not routinely necessary."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop all athletic activity until skeletal maturity is complete is inappropriate because long-term restriction through skeletal maturity is not routinely necessary."
            },
            {
              "id": "B",
              "text": "Option A: Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
            },
            {
              "id": "C",
              "text": "Option B: Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop all athletic activity until skeletal maturity is complete is inappropriate because long-term restriction through skeletal maturity is not routinely necessary."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase dietary calcium intake and continue full participation is inappropriate because calcium intake alone does not treat an overuse injury of the pars interarticularis."
            },
            {
              "id": "B",
              "text": "Option A: Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
            },
            {
              "id": "C",
              "text": "Option B: Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase dietary calcium intake and continue full participation is inappropriate because calcium intake alone does not treat an overuse injury of the pars interarticularis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue vaulting after taking a nonsteroidal anti-inflammatory drug before practice is inappropriate because analgesia may reduce perceived pain but does not remove the repetitive extension stress causing a suspected pars injury. Premedication should not be used to permit continued painful participation."
            },
            {
              "id": "B",
              "text": "Option A: Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
            },
            {
              "id": "C",
              "text": "Option B: Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue vaulting after taking a nonsteroidal anti-inflammatory drug before practice is inappropriate because analgesia may reduce perceived pain but does not remove the repetitive extension stress causing a suspected pars injury. Premedication should not be used to permit continued painful participation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Resume full participation as soon as the pain begins to improve, without completing rehabilitation is inappropriate because symptom improvement alone is insufficient. Return should follow pain resolution, restoration of normal examination and function, rehabilitation, and graded sport-specific progression."
            },
            {
              "id": "B",
              "text": "Option A: Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
            },
            {
              "id": "C",
              "text": "Option B: Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Resume full participation as soon as the pain begins to improve, without completing rehabilitation is inappropriate because symptom improvement alone is insufficient. Return should follow pain resolution, restoration of normal examination and function, rehabilitation, and graded sport-specific progression."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Undergo immediate surgical repair of the pars defect before returning to sport is inappropriate because initial treatment is nonoperative activity modification and rehabilitation. Surgery is reserved for persistent symptoms after a prolonged, comprehensive conservative program."
            },
            {
              "id": "B",
              "text": "Option A: Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
            },
            {
              "id": "C",
              "text": "Option B: Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Undergo immediate surgical repair of the pars defect before returning to sport is inappropriate because initial treatment is nonoperative activity modification and rehabilitation. Surgery is reserved for persistent symptoms after a prolonged, comprehensive conservative program."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remain on strict bed rest until the back pain has completely resolved is inappropriate because restriction from the painful sport is appropriate, but strict bed rest causes deconditioning and is not required. Rehabilitation can begin while sport participation remains restricted."
            },
            {
              "id": "B",
              "text": "Option A: Continue vaulting if he uses a lumbar brace during practices is inappropriate because a brace may be used in selected cases, but it does not justify continuing painful extension-based sport participation."
            },
            {
              "id": "C",
              "text": "Option B: Continue training because the neurologic examination is normal is inappropriate because a normal neurologic examination does not exclude a pars stress injury or permit continued painful activity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remain on strict bed rest until the back pain has completely resolved is inappropriate because restriction from the painful sport is appropriate, but strict bed rest causes deconditioning and is not required. Rehabilitation can begin while sport participation remains restricted."
        }
      }
    },
    {
      "externalId": "nbme5-s5-i044-diclofenac-hemodynamic-aki",
      "expectedHashes": {
        "ranaze_step3_uat": "f4bb746ef1d2b63e6af09e24f04d3a7a2a4a681e792f4b62f52f339d5c3ca087",
        "ranaze_step3_prd": "f4bb746ef1d2b63e6af09e24f04d3a7a2a4a681e792f4b62f52f339d5c3ca087"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amlodipine does not typically cause an acute reduction in glomerular filtration rate."
            },
            {
              "id": "B",
              "text": "Option B: Bumetanide can cause prerenal acute kidney injury after excessive diuresis, but this patient has jugular venous distension, rales, and peripheral edema rather than findings of volume depletion; newly started diclofenac is the stronger cause."
            },
            {
              "id": "C",
              "text": "Option D: Escitalopram is not a typical direct cause of an acute rise in serum creatinine concentration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amlodipine does not typically cause an acute reduction in glomerular filtration rate."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bumetanide can cause prerenal acute kidney injury after excessive diuresis, but this patient has jugular venous distension, rales, and peripheral edema rather than findings of volume depletion; newly started diclofenac is the stronger cause."
            },
            {
              "id": "B",
              "text": "Option A: Amlodipine does not typically cause an acute reduction in glomerular filtration rate."
            },
            {
              "id": "C",
              "text": "Option D: Escitalopram is not a typical direct cause of an acute rise in serum creatinine concentration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bumetanide can cause prerenal acute kidney injury after excessive diuresis, but this patient has jugular venous distension, rales, and peripheral edema rather than findings of volume depletion; newly started diclofenac is the stronger cause."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Escitalopram is not a typical direct cause of an acute rise in serum creatinine concentration."
            },
            {
              "id": "B",
              "text": "Option A: Amlodipine does not typically cause an acute reduction in glomerular filtration rate."
            },
            {
              "id": "C",
              "text": "Option B: Bumetanide can cause prerenal acute kidney injury after excessive diuresis, but this patient has jugular venous distension, rales, and peripheral edema rather than findings of volume depletion; newly started diclofenac is the stronger cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Escitalopram is not a typical direct cause of an acute rise in serum creatinine concentration."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sitagliptin is not a typical cause of hemodynamic acute kidney injury; the recent NSAID exposure provides a more direct explanation."
            },
            {
              "id": "B",
              "text": "Option A: Amlodipine does not typically cause an acute reduction in glomerular filtration rate."
            },
            {
              "id": "C",
              "text": "Option B: Bumetanide can cause prerenal acute kidney injury after excessive diuresis, but this patient has jugular venous distension, rales, and peripheral edema rather than findings of volume depletion; newly started diclofenac is the stronger cause."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sitagliptin is not a typical cause of hemodynamic acute kidney injury; the recent NSAID exposure provides a more direct explanation."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i002-influenza-vaccine-workplace-prevention",
      "expectedHashes": {
        "ranaze_step3_uat": "7572ca1ccc21930ec82ac96448b5607e4102b96a913b62d594b0be12c1fd82f6",
        "ranaze_step3_prd": "7572ca1ccc21930ec82ac96448b5607e4102b96a913b62d594b0be12c1fd82f6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The vaccine is not recommended because the risk of adverse effects outweighs the benefit in adults her age is inappropriate because in a healthy adult, expected benefit from annual influenza vaccination exceeds the small risk of adverse effects."
            },
            {
              "id": "B",
              "text": "Option B: The vaccine is inappropriate because women taking oral contraceptives should avoid influenza vaccination is inappropriate because use of combined oral contraceptives does not make influenza vaccination inappropriate."
            },
            {
              "id": "C",
              "text": "Option C: The vaccine is mainly useful for adults with chronic cardiopulmonary disease, so she is unlikely to benefit is inappropriate because influenza vaccination is beneficial even in adults without chronic cardiopulmonary disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The vaccine is not recommended because the risk of adverse effects outweighs the benefit in adults her age is inappropriate because in a healthy adult, expected benefit from annual influenza vaccination exceeds the small risk of adverse effects."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The vaccine is inappropriate because women taking oral contraceptives should avoid influenza vaccination is inappropriate because use of combined oral contraceptives does not make influenza vaccination inappropriate."
            },
            {
              "id": "B",
              "text": "Option A: The vaccine is not recommended because the risk of adverse effects outweighs the benefit in adults her age is inappropriate because in a healthy adult, expected benefit from annual influenza vaccination exceeds the small risk of adverse effects."
            },
            {
              "id": "C",
              "text": "Option C: The vaccine is mainly useful for adults with chronic cardiopulmonary disease, so she is unlikely to benefit is inappropriate because influenza vaccination is beneficial even in adults without chronic cardiopulmonary disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The vaccine is inappropriate because women taking oral contraceptives should avoid influenza vaccination is inappropriate because use of combined oral contraceptives does not make influenza vaccination inappropriate."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The vaccine is mainly useful for adults with chronic cardiopulmonary disease, so she is unlikely to benefit is inappropriate because influenza vaccination is beneficial even in adults without chronic cardiopulmonary disease."
            },
            {
              "id": "B",
              "text": "Option A: The vaccine is not recommended because the risk of adverse effects outweighs the benefit in adults her age is inappropriate because in a healthy adult, expected benefit from annual influenza vaccination exceeds the small risk of adverse effects."
            },
            {
              "id": "C",
              "text": "Option B: The vaccine is inappropriate because women taking oral contraceptives should avoid influenza vaccination is inappropriate because use of combined oral contraceptives does not make influenza vaccination inappropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The vaccine is mainly useful for adults with chronic cardiopulmonary disease, so she is unlikely to benefit is inappropriate because influenza vaccination is beneficial even in adults without chronic cardiopulmonary disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She should wait until influenza is circulating widely before deciding whether to be vaccinated is inappropriate because vaccination should be given before or during the influenza season, not deferred until widespread transmission is obvious."
            },
            {
              "id": "B",
              "text": "Option A: The vaccine is not recommended because the risk of adverse effects outweighs the benefit in adults her age is inappropriate because in a healthy adult, expected benefit from annual influenza vaccination exceeds the small risk of adverse effects."
            },
            {
              "id": "C",
              "text": "Option B: The vaccine is inappropriate because women taking oral contraceptives should avoid influenza vaccination is inappropriate because use of combined oral contraceptives does not make influenza vaccination inappropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She should wait until influenza is circulating widely before deciding whether to be vaccinated is inappropriate because vaccination should be given before or during the influenza season, not deferred until widespread transmission is obvious."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She does not need vaccination because having influenza last winter provides sufficient protection this year is inappropriate because prior influenza infection from a previous season does not eliminate the need for annual vaccination."
            },
            {
              "id": "B",
              "text": "Option A: The vaccine is not recommended because the risk of adverse effects outweighs the benefit in adults her age is inappropriate because in a healthy adult, expected benefit from annual influenza vaccination exceeds the small risk of adverse effects."
            },
            {
              "id": "C",
              "text": "Option B: The vaccine is inappropriate because women taking oral contraceptives should avoid influenza vaccination is inappropriate because use of combined oral contraceptives does not make influenza vaccination inappropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She does not need vaccination because having influenza last winter provides sufficient protection this year is inappropriate because prior influenza infection from a previous season does not eliminate the need for annual vaccination."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She should not be vaccinated unless she first develops respiratory symptoms during the winter is inappropriate because influenza vaccine is used for prevention, not as a treatment after symptoms begin."
            },
            {
              "id": "B",
              "text": "Option A: The vaccine is not recommended because the risk of adverse effects outweighs the benefit in adults her age is inappropriate because in a healthy adult, expected benefit from annual influenza vaccination exceeds the small risk of adverse effects."
            },
            {
              "id": "C",
              "text": "Option B: The vaccine is inappropriate because women taking oral contraceptives should avoid influenza vaccination is inappropriate because use of combined oral contraceptives does not make influenza vaccination inappropriate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She should not be vaccinated unless she first develops respiratory symptoms during the winter is inappropriate because influenza vaccine is used for prevention, not as a treatment after symptoms begin."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i003-pneumococcal-vaccine-average-risk-adult",
      "expectedHashes": {
        "ranaze_step3_uat": "0821531c9902a2d4b94488da4b3303cd7c9d0fc1a37a055d71cf185446389a53",
        "ranaze_step3_prd": "0821531c9902a2d4b94488da4b3303cd7c9d0fc1a37a055d71cf185446389a53"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Revaccination now is recommended because any adult with uncertain vaccine history should receive repeated doses is inappropriate because uncertain remote history alone does not justify routine repeated pneumococcal vaccination in an otherwise average-risk 42-year-old adult."
            },
            {
              "id": "B",
              "text": "Option B: She should be vaccinated now because pneumococcal disease is especially common in otherwise healthy adults in their early 40s is inappropriate because pneumococcal disease risk is higher at older ages and in selected high-risk groups, not simply because a patient is in her early 40s."
            },
            {
              "id": "C",
              "text": "Option C: Revaccination should be avoided because severe serum sickness is expected after any repeat pneumococcal dose is inappropriate because severe serum sickness is not an expected outcome after repeat pneumococcal vaccination; this overstates the adverse-event risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Revaccination now is recommended because any adult with uncertain vaccine history should receive repeated doses is inappropriate because uncertain remote history alone does not justify routine repeated pneumococcal vaccination in an otherwise average-risk 42-year-old adult."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She should be vaccinated now because pneumococcal disease is especially common in otherwise healthy adults in their early 40s is inappropriate because pneumococcal disease risk is higher at older ages and in selected high-risk groups, not simply because a patient is in her early 40s."
            },
            {
              "id": "B",
              "text": "Option A: Revaccination now is recommended because any adult with uncertain vaccine history should receive repeated doses is inappropriate because uncertain remote history alone does not justify routine repeated pneumococcal vaccination in an otherwise average-risk 42-year-old adult."
            },
            {
              "id": "C",
              "text": "Option C: Revaccination should be avoided because severe serum sickness is expected after any repeat pneumococcal dose is inappropriate because severe serum sickness is not an expected outcome after repeat pneumococcal vaccination; this overstates the adverse-event risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She should be vaccinated now because pneumococcal disease is especially common in otherwise healthy adults in their early 40s is inappropriate because pneumococcal disease risk is higher at older ages and in selected high-risk groups, not simply because a patient is in her early 40s."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Revaccination should be avoided because severe serum sickness is expected after any repeat pneumococcal dose is inappropriate because severe serum sickness is not an expected outcome after repeat pneumococcal vaccination; this overstates the adverse-event risk."
            },
            {
              "id": "B",
              "text": "Option A: Revaccination now is recommended because any adult with uncertain vaccine history should receive repeated doses is inappropriate because uncertain remote history alone does not justify routine repeated pneumococcal vaccination in an otherwise average-risk 42-year-old adult."
            },
            {
              "id": "C",
              "text": "Option B: She should be vaccinated now because pneumococcal disease is especially common in otherwise healthy adults in their early 40s is inappropriate because pneumococcal disease risk is higher at older ages and in selected high-risk groups, not simply because a patient is in her early 40s."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Revaccination should be avoided because severe serum sickness is expected after any repeat pneumococcal dose is inappropriate because severe serum sickness is not an expected outcome after repeat pneumococcal vaccination; this overstates the adverse-event risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pneumococcal vaccination is contraindicated in endurance athletes because of reduced training tolerance is inappropriate because endurance training is not a contraindication to pneumococcal vaccination."
            },
            {
              "id": "B",
              "text": "Option A: Revaccination now is recommended because any adult with uncertain vaccine history should receive repeated doses is inappropriate because uncertain remote history alone does not justify routine repeated pneumococcal vaccination in an otherwise average-risk 42-year-old adult."
            },
            {
              "id": "C",
              "text": "Option B: She should be vaccinated now because pneumococcal disease is especially common in otherwise healthy adults in their early 40s is inappropriate because pneumococcal disease risk is higher at older ages and in selected high-risk groups, not simply because a patient is in her early 40s."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pneumococcal vaccination is contraindicated in endurance athletes because of reduced training tolerance is inappropriate because endurance training is not a contraindication to pneumococcal vaccination."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Antibody titers should be checked first because they determine routine vaccination needs in healthy adults is inappropriate because routine pneumococcal vaccine decisions in healthy adults are based on age and risk conditions, not screening antibody titers."
            },
            {
              "id": "B",
              "text": "Option A: Revaccination now is recommended because any adult with uncertain vaccine history should receive repeated doses is inappropriate because uncertain remote history alone does not justify routine repeated pneumococcal vaccination in an otherwise average-risk 42-year-old adult."
            },
            {
              "id": "C",
              "text": "Option B: She should be vaccinated now because pneumococcal disease is especially common in otherwise healthy adults in their early 40s is inappropriate because pneumococcal disease risk is higher at older ages and in selected high-risk groups, not simply because a patient is in her early 40s."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Antibody titers should be checked first because they determine routine vaccination needs in healthy adults is inappropriate because routine pneumococcal vaccine decisions in healthy adults are based on age and risk conditions, not screening antibody titers."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vaccination is needed only if she first develops an episode of bacterial pneumonia is inappropriate because vaccination is preventive, not something that should be withheld until after disease occurs; however, she still does not currently meet routine indication criteria."
            },
            {
              "id": "B",
              "text": "Option A: Revaccination now is recommended because any adult with uncertain vaccine history should receive repeated doses is inappropriate because uncertain remote history alone does not justify routine repeated pneumococcal vaccination in an otherwise average-risk 42-year-old adult."
            },
            {
              "id": "C",
              "text": "Option B: She should be vaccinated now because pneumococcal disease is especially common in otherwise healthy adults in their early 40s is inappropriate because pneumococcal disease risk is higher at older ages and in selected high-risk groups, not simply because a patient is in her early 40s."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vaccination is needed only if she first develops an episode of bacterial pneumonia is inappropriate because vaccination is preventive, not something that should be withheld until after disease occurs; however, she still does not currently meet routine indication criteria."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i005-trial-significance-indicator",
      "expectedHashes": {
        "ranaze_step3_uat": "a3210ad8c1835515a137f088284587c379cc6307e2047e6a5b221b42847d5d17",
        "ranaze_step3_prd": "a3210ad8c1835515a137f088284587c379cc6307e2047e6a5b221b42847d5d17"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The comparison has the largest absolute difference in completion percentages is inappropriate because a larger absolute difference can still be compatible with random variation if the comparison is imprecise or not statistically significant."
            },
            {
              "id": "B",
              "text": "Option B: The comparison has the narrowest 95% confidence interval is inappropriate because a narrower confidence interval indicates greater precision, not by itself a true between-group difference."
            },
            {
              "id": "C",
              "text": "Option C: The odds ratio is farthest from 1.0 is inappropriate because an odds ratio farther from 1.0 suggests a larger effect estimate, but statistical significance still depends on variability and sample size."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The comparison has the largest absolute difference in completion percentages is inappropriate because a larger absolute difference can still be compatible with random variation if the comparison is imprecise or not statistically significant."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The comparison has the narrowest 95% confidence interval is inappropriate because a narrower confidence interval indicates greater precision, not by itself a true between-group difference."
            },
            {
              "id": "B",
              "text": "Option A: The comparison has the largest absolute difference in completion percentages is inappropriate because a larger absolute difference can still be compatible with random variation if the comparison is imprecise or not statistically significant."
            },
            {
              "id": "C",
              "text": "Option C: The odds ratio is farthest from 1.0 is inappropriate because an odds ratio farther from 1.0 suggests a larger effect estimate, but statistical significance still depends on variability and sample size."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The comparison has the narrowest 95% confidence interval is inappropriate because a narrower confidence interval indicates greater precision, not by itself a true between-group difference."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The odds ratio is farthest from 1.0 is inappropriate because an odds ratio farther from 1.0 suggests a larger effect estimate, but statistical significance still depends on variability and sample size."
            },
            {
              "id": "B",
              "text": "Option A: The comparison has the largest absolute difference in completion percentages is inappropriate because a larger absolute difference can still be compatible with random variation if the comparison is imprecise or not statistically significant."
            },
            {
              "id": "C",
              "text": "Option B: The comparison has the narrowest 95% confidence interval is inappropriate because a narrower confidence interval indicates greater precision, not by itself a true between-group difference."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The odds ratio is farthest from 1.0 is inappropriate because an odds ratio farther from 1.0 suggests a larger effect estimate, but statistical significance still depends on variability and sample size."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Baseline covariates appear well balanced between groups is inappropriate because balanced baseline covariates support internal validity, but they do not establish that an observed outcome difference is statistically significant."
            },
            {
              "id": "B",
              "text": "Option A: The comparison has the largest absolute difference in completion percentages is inappropriate because a larger absolute difference can still be compatible with random variation if the comparison is imprecise or not statistically significant."
            },
            {
              "id": "C",
              "text": "Option B: The comparison has the narrowest 95% confidence interval is inappropriate because a narrower confidence interval indicates greater precision, not by itself a true between-group difference."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Baseline covariates appear well balanced between groups is inappropriate because balanced baseline covariates support internal validity, but they do not establish that an observed outcome difference is statistically significant."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "One study arm contains the largest number of participants is inappropriate because a larger arm can improve power, but sample size alone does not show that a specific comparison found a true difference."
            },
            {
              "id": "B",
              "text": "Option A: The comparison has the largest absolute difference in completion percentages is inappropriate because a larger absolute difference can still be compatible with random variation if the comparison is imprecise or not statistically significant."
            },
            {
              "id": "C",
              "text": "Option B: The comparison has the narrowest 95% confidence interval is inappropriate because a narrower confidence interval indicates greater precision, not by itself a true between-group difference."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "One study arm contains the largest number of participants is inappropriate because a larger arm can improve power, but sample size alone does not show that a specific comparison found a true difference."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The intervention rankings are consistent across all pairwise comparisons is inappropriate because consistent ranking may be clinically interesting, but it does not determine whether any pairwise difference is statistically significant."
            },
            {
              "id": "B",
              "text": "Option A: The comparison has the largest absolute difference in completion percentages is inappropriate because a larger absolute difference can still be compatible with random variation if the comparison is imprecise or not statistically significant."
            },
            {
              "id": "C",
              "text": "Option B: The comparison has the narrowest 95% confidence interval is inappropriate because a narrower confidence interval indicates greater precision, not by itself a true between-group difference."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The intervention rankings are consistent across all pairwise comparisons is inappropriate because consistent ranking may be clinically interesting, but it does not determine whether any pairwise difference is statistically significant."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i007-peg-poor-prognostic-marker",
      "expectedHashes": {
        "ranaze_step3_uat": "7ec807349f449623986a38970c2834ba8b1197c6d15ea0a6fb6ddb25d167f36d",
        "ranaze_step3_prd": "7ec807349f449623986a38970c2834ba8b1197c6d15ea0a6fb6ddb25d167f36d"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "PEG placement is contraindicated in all patients with severe neurologic disease is inappropriate because advanced neurologic disease alone is not an absolute contraindication to PEG placement."
            },
            {
              "id": "B",
              "text": "Option B: The procedure itself is probably the main cause of the observed 1-year mortality is inappropriate because these observational data do not establish causation; the underlying illness severity likely explains much of the mortality."
            },
            {
              "id": "C",
              "text": "Option C: The European-style outcomes prove that care quality was worse in the second cohort is inappropriate because differences between cohorts do not prove differences in care quality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "PEG placement is contraindicated in all patients with severe neurologic disease is inappropriate because advanced neurologic disease alone is not an absolute contraindication to PEG placement."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The procedure itself is probably the main cause of the observed 1-year mortality is inappropriate because these observational data do not establish causation; the underlying illness severity likely explains much of the mortality."
            },
            {
              "id": "B",
              "text": "Option A: PEG placement is contraindicated in all patients with severe neurologic disease is inappropriate because advanced neurologic disease alone is not an absolute contraindication to PEG placement."
            },
            {
              "id": "C",
              "text": "Option C: The European-style outcomes prove that care quality was worse in the second cohort is inappropriate because differences between cohorts do not prove differences in care quality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The procedure itself is probably the main cause of the observed 1-year mortality is inappropriate because these observational data do not establish causation; the underlying illness severity likely explains much of the mortality."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The European-style outcomes prove that care quality was worse in the second cohort is inappropriate because differences between cohorts do not prove differences in care quality."
            },
            {
              "id": "B",
              "text": "Option A: PEG placement is contraindicated in all patients with severe neurologic disease is inappropriate because advanced neurologic disease alone is not an absolute contraindication to PEG placement."
            },
            {
              "id": "C",
              "text": "Option B: The procedure itself is probably the main cause of the observed 1-year mortality is inappropriate because these observational data do not establish causation; the underlying illness severity likely explains much of the mortality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The European-style outcomes prove that care quality was worse in the second cohort is inappropriate because differences between cohorts do not prove differences in care quality."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Enteral feeding should be withheld because survival beyond 30 days is impossible is inappropriate because the reported 30-day mortality is high, but not all patients die within 30 days."
            },
            {
              "id": "B",
              "text": "Option A: PEG placement is contraindicated in all patients with severe neurologic disease is inappropriate because advanced neurologic disease alone is not an absolute contraindication to PEG placement."
            },
            {
              "id": "C",
              "text": "Option B: The procedure itself is probably the main cause of the observed 1-year mortality is inappropriate because these observational data do not establish causation; the underlying illness severity likely explains much of the mortality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Enteral feeding should be withheld because survival beyond 30 days is impossible is inappropriate because the reported 30-day mortality is high, but not all patients die within 30 days."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "These studies show that PEG placement is being overused is inappropriate because utilization patterns cannot be determined from these mortality data alone."
            },
            {
              "id": "B",
              "text": "Option A: PEG placement is contraindicated in all patients with severe neurologic disease is inappropriate because advanced neurologic disease alone is not an absolute contraindication to PEG placement."
            },
            {
              "id": "C",
              "text": "Option B: The procedure itself is probably the main cause of the observed 1-year mortality is inappropriate because these observational data do not establish causation; the underlying illness severity likely explains much of the mortality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "These studies show that PEG placement is being overused is inappropriate because utilization patterns cannot be determined from these mortality data alone."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mortality should not be discussed because both studies were retrospective is inappropriate because retrospective data can still be useful for counseling about prognosis, even though they are less suited to causal inference."
            },
            {
              "id": "B",
              "text": "Option A: PEG placement is contraindicated in all patients with severe neurologic disease is inappropriate because advanced neurologic disease alone is not an absolute contraindication to PEG placement."
            },
            {
              "id": "C",
              "text": "Option B: The procedure itself is probably the main cause of the observed 1-year mortality is inappropriate because these observational data do not establish causation; the underlying illness severity likely explains much of the mortality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mortality should not be discussed because both studies were retrospective is inappropriate because retrospective data can still be useful for counseling about prognosis, even though they are less suited to causal inference."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i008-copd-from-obstructive-spirometry",
      "expectedHashes": {
        "ranaze_step3_uat": "d6d317daacc43a5c86cd9ddc98c6a76cb293ae5cf0ffd104d60b81ef6b96b381",
        "ranaze_step3_prd": "d6d317daacc43a5c86cd9ddc98c6a76cb293ae5cf0ffd104d60b81ef6b96b381"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Asthma usually has more reversible airflow obstruction; this patient has only a 4% FEV1 increase after bronchodilator and has hyperinflation with reduced DLCO in the setting of heavy smoking."
            },
            {
              "id": "B",
              "text": "Option C: Bronchiectasis typically causes recurrent infections and often larger-volume purulent sputum; the x-ray here shows hyperinflation without focal bronchiectatic changes."
            },
            {
              "id": "C",
              "text": "Option D: Heart failure with pulmonary congestion is inappropriate because heart failure would be more likely to cause orthopnea, crackles, edema, or pulmonary vascular congestion rather than persistent obstructive spirometry with hyperinflation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Asthma usually has more reversible airflow obstruction; this patient has only a 4% FEV1 increase after bronchodilator and has hyperinflation with reduced DLCO in the setting of heavy smoking."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bronchiectasis typically causes recurrent infections and often larger-volume purulent sputum; the x-ray here shows hyperinflation without focal bronchiectatic changes."
            },
            {
              "id": "B",
              "text": "Option A: Asthma usually has more reversible airflow obstruction; this patient has only a 4% FEV1 increase after bronchodilator and has hyperinflation with reduced DLCO in the setting of heavy smoking."
            },
            {
              "id": "C",
              "text": "Option D: Heart failure with pulmonary congestion is inappropriate because heart failure would be more likely to cause orthopnea, crackles, edema, or pulmonary vascular congestion rather than persistent obstructive spirometry with hyperinflation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bronchiectasis typically causes recurrent infections and often larger-volume purulent sputum; the x-ray here shows hyperinflation without focal bronchiectatic changes."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Heart failure with pulmonary congestion is inappropriate because heart failure would be more likely to cause orthopnea, crackles, edema, or pulmonary vascular congestion rather than persistent obstructive spirometry with hyperinflation."
            },
            {
              "id": "B",
              "text": "Option A: Asthma usually has more reversible airflow obstruction; this patient has only a 4% FEV1 increase after bronchodilator and has hyperinflation with reduced DLCO in the setting of heavy smoking."
            },
            {
              "id": "C",
              "text": "Option C: Bronchiectasis typically causes recurrent infections and often larger-volume purulent sputum; the x-ray here shows hyperinflation without focal bronchiectatic changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Heart failure with pulmonary congestion is inappropriate because heart failure would be more likely to cause orthopnea, crackles, edema, or pulmonary vascular congestion rather than persistent obstructive spirometry with hyperinflation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hypersensitivity pneumonitis usually causes a restrictive pattern and diffuse inflammatory findings, not chronic obstruction with increased total lung capacity."
            },
            {
              "id": "B",
              "text": "Option A: Asthma usually has more reversible airflow obstruction; this patient has only a 4% FEV1 increase after bronchodilator and has hyperinflation with reduced DLCO in the setting of heavy smoking."
            },
            {
              "id": "C",
              "text": "Option C: Bronchiectasis typically causes recurrent infections and often larger-volume purulent sputum; the x-ray here shows hyperinflation without focal bronchiectatic changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hypersensitivity pneumonitis usually causes a restrictive pattern and diffuse inflammatory findings, not chronic obstruction with increased total lung capacity."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lung cancer causing endobronchial obstruction is inappropriate because endobronchial malignancy is more likely to produce a focal radiographic abnormality, hemoptysis, or localized obstruction rather than diffuse hyperinflation and chronic stable sputum."
            },
            {
              "id": "B",
              "text": "Option A: Asthma usually has more reversible airflow obstruction; this patient has only a 4% FEV1 increase after bronchodilator and has hyperinflation with reduced DLCO in the setting of heavy smoking."
            },
            {
              "id": "C",
              "text": "Option C: Bronchiectasis typically causes recurrent infections and often larger-volume purulent sputum; the x-ray here shows hyperinflation without focal bronchiectatic changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lung cancer causing endobronchial obstruction is inappropriate because endobronchial malignancy is more likely to produce a focal radiographic abnormality, hemoptysis, or localized obstruction rather than diffuse hyperinflation and chronic stable sputum."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alpha-1 antitrypsin deficiency emphysema is more likely with younger age and limited smoking exposure; this patient\u2019s heavy smoking history makes typical smoking-related chronic obstructive pulmonary disease more likely."
            },
            {
              "id": "B",
              "text": "Option A: Asthma usually has more reversible airflow obstruction; this patient has only a 4% FEV1 increase after bronchodilator and has hyperinflation with reduced DLCO in the setting of heavy smoking."
            },
            {
              "id": "C",
              "text": "Option C: Bronchiectasis typically causes recurrent infections and often larger-volume purulent sputum; the x-ray here shows hyperinflation without focal bronchiectatic changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alpha-1 antitrypsin deficiency emphysema is more likely with younger age and limited smoking exposure; this patient\u2019s heavy smoking history makes typical smoking-related chronic obstructive pulmonary disease more likely."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i009-rh-positive-pregnancy-reassurance",
      "expectedHashes": {
        "ranaze_step3_uat": "2d49d077d7f695c69564557eff99e3adaf3463ff64ef1bd4749359f5c957d56a",
        "ranaze_step3_prd": "2d49d077d7f695c69564557eff99e3adaf3463ff64ef1bd4749359f5c957d56a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a repeat maternal antibody screen today because the partner is Rh-negative is inappropriate because repeat antibody testing is not indicated solely because the partner is Rh-negative; maternal Rh-positive status makes anti-D alloimmunization the relevant issue here unlikely."
            },
            {
              "id": "B",
              "text": "Option B: Arrange middle cerebral artery Doppler surveillance of the fetus is inappropriate because fetal anemia surveillance with middle cerebral artery Doppler is used when there is concern for significant alloimmunization, which is not suggested here."
            },
            {
              "id": "C",
              "text": "Option C: Administer Rho(D) immune globulin now is inappropriate because rho(D) immune globulin is used for unsensitized Rh-negative pregnant patients, not Rh-positive patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a repeat maternal antibody screen today because the partner is Rh-negative is inappropriate because repeat antibody testing is not indicated solely because the partner is Rh-negative; maternal Rh-positive status makes anti-D alloimmunization the relevant issue here unlikely."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange middle cerebral artery Doppler surveillance of the fetus is inappropriate because fetal anemia surveillance with middle cerebral artery Doppler is used when there is concern for significant alloimmunization, which is not suggested here."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a repeat maternal antibody screen today because the partner is Rh-negative is inappropriate because repeat antibody testing is not indicated solely because the partner is Rh-negative; maternal Rh-positive status makes anti-D alloimmunization the relevant issue here unlikely."
            },
            {
              "id": "C",
              "text": "Option C: Administer Rho(D) immune globulin now is inappropriate because rho(D) immune globulin is used for unsensitized Rh-negative pregnant patients, not Rh-positive patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange middle cerebral artery Doppler surveillance of the fetus is inappropriate because fetal anemia surveillance with middle cerebral artery Doppler is used when there is concern for significant alloimmunization, which is not suggested here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer Rho(D) immune globulin now is inappropriate because rho(D) immune globulin is used for unsensitized Rh-negative pregnant patients, not Rh-positive patients."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a repeat maternal antibody screen today because the partner is Rh-negative is inappropriate because repeat antibody testing is not indicated solely because the partner is Rh-negative; maternal Rh-positive status makes anti-D alloimmunization the relevant issue here unlikely."
            },
            {
              "id": "C",
              "text": "Option B: Arrange middle cerebral artery Doppler surveillance of the fetus is inappropriate because fetal anemia surveillance with middle cerebral artery Doppler is used when there is concern for significant alloimmunization, which is not suggested here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer Rho(D) immune globulin now is inappropriate because rho(D) immune globulin is used for unsensitized Rh-negative pregnant patients, not Rh-positive patients."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer her for immediate maternal-fetal medicine consultation is inappropriate because immediate high-risk referral is unnecessary because there is no evidence of Rh-mediated fetal risk in an Rh-positive mother."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a repeat maternal antibody screen today because the partner is Rh-negative is inappropriate because repeat antibody testing is not indicated solely because the partner is Rh-negative; maternal Rh-positive status makes anti-D alloimmunization the relevant issue here unlikely."
            },
            {
              "id": "C",
              "text": "Option B: Arrange middle cerebral artery Doppler surveillance of the fetus is inappropriate because fetal anemia surveillance with middle cerebral artery Doppler is used when there is concern for significant alloimmunization, which is not suggested here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer her for immediate maternal-fetal medicine consultation is inappropriate because immediate high-risk referral is unnecessary because there is no evidence of Rh-mediated fetal risk in an Rh-positive mother."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule amniocentesis to determine fetal blood type is inappropriate because determining fetal blood type invasively is not the initial step and is unnecessary when the mother is Rh-positive."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a repeat maternal antibody screen today because the partner is Rh-negative is inappropriate because repeat antibody testing is not indicated solely because the partner is Rh-negative; maternal Rh-positive status makes anti-D alloimmunization the relevant issue here unlikely."
            },
            {
              "id": "C",
              "text": "Option B: Arrange middle cerebral artery Doppler surveillance of the fetus is inappropriate because fetal anemia surveillance with middle cerebral artery Doppler is used when there is concern for significant alloimmunization, which is not suggested here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule amniocentesis to determine fetal blood type is inappropriate because determining fetal blood type invasively is not the initial step and is unnecessary when the mother is Rh-positive."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plan prophylactic Rho(D) immune globulin at 28 weeks\u0027 gestation is inappropriate because routine 28-week Rho(D) immune globulin prophylaxis is for Rh-negative pregnant patients, not for this Rh-positive patient."
            },
            {
              "id": "B",
              "text": "Option A: Obtain a repeat maternal antibody screen today because the partner is Rh-negative is inappropriate because repeat antibody testing is not indicated solely because the partner is Rh-negative; maternal Rh-positive status makes anti-D alloimmunization the relevant issue here unlikely."
            },
            {
              "id": "C",
              "text": "Option B: Arrange middle cerebral artery Doppler surveillance of the fetus is inappropriate because fetal anemia surveillance with middle cerebral artery Doppler is used when there is concern for significant alloimmunization, which is not suggested here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plan prophylactic Rho(D) immune globulin at 28 weeks\u0027 gestation is inappropriate because routine 28-week Rho(D) immune globulin prophylaxis is for Rh-negative pregnant patients, not for this Rh-positive patient."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i010-hiv-oral-hairy-leukoplakia-art",
      "expectedHashes": {
        "ranaze_step3_uat": "06f5572e9388299c4a567c47b22192ad76a4fd3e48b09811db4a97f28a8a3751",
        "ranaze_step3_prd": "06f5572e9388299c4a567c47b22192ad76a4fd3e48b09811db4a97f28a8a3751"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical nystatin suspension is inappropriate because topical nystatin is used for oral candidiasis, which typically causes removable white plaques; these plaques do not scrape off."
            },
            {
              "id": "B",
              "text": "Option B: Oral fluconazole treats candidiasis, especially with esophageal or refractory disease, but this lesion is not described as thrush."
            },
            {
              "id": "C",
              "text": "Option C: Prednisone taper is inappropriate because prednisone would not treat this HIV-associated tongue lesion and could worsen immune control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical nystatin suspension is inappropriate because topical nystatin is used for oral candidiasis, which typically causes removable white plaques; these plaques do not scrape off."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral fluconazole treats candidiasis, especially with esophageal or refractory disease, but this lesion is not described as thrush."
            },
            {
              "id": "B",
              "text": "Option A: Topical nystatin suspension is inappropriate because topical nystatin is used for oral candidiasis, which typically causes removable white plaques; these plaques do not scrape off."
            },
            {
              "id": "C",
              "text": "Option C: Prednisone taper is inappropriate because prednisone would not treat this HIV-associated tongue lesion and could worsen immune control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral fluconazole treats candidiasis, especially with esophageal or refractory disease, but this lesion is not described as thrush."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prednisone taper is inappropriate because prednisone would not treat this HIV-associated tongue lesion and could worsen immune control."
            },
            {
              "id": "B",
              "text": "Option A: Topical nystatin suspension is inappropriate because topical nystatin is used for oral candidiasis, which typically causes removable white plaques; these plaques do not scrape off."
            },
            {
              "id": "C",
              "text": "Option B: Oral fluconazole treats candidiasis, especially with esophageal or refractory disease, but this lesion is not described as thrush."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prednisone taper is inappropriate because prednisone would not treat this HIV-associated tongue lesion and could worsen immune control."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Excisional biopsy of the tongue lesion is inappropriate because biopsy is not the best next step when the lesion is clinically characteristic and the patient has untreated HIV; HIV treatment should be started now."
            },
            {
              "id": "B",
              "text": "Option A: Topical nystatin suspension is inappropriate because topical nystatin is used for oral candidiasis, which typically causes removable white plaques; these plaques do not scrape off."
            },
            {
              "id": "C",
              "text": "Option B: Oral fluconazole treats candidiasis, especially with esophageal or refractory disease, but this lesion is not described as thrush."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Excisional biopsy of the tongue lesion is inappropriate because biopsy is not the best next step when the lesion is clinically characteristic and the patient has untreated HIV; HIV treatment should be started now."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral acyclovir is inappropriate because acyclovir is not standard treatment for oral hairy leukoplakia and does not address the central management issue of untreated HIV."
            },
            {
              "id": "B",
              "text": "Option A: Topical nystatin suspension is inappropriate because topical nystatin is used for oral candidiasis, which typically causes removable white plaques; these plaques do not scrape off."
            },
            {
              "id": "C",
              "text": "Option B: Oral fluconazole treats candidiasis, especially with esophageal or refractory disease, but this lesion is not described as thrush."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral acyclovir is inappropriate because acyclovir is not standard treatment for oral hairy leukoplakia and does not address the central management issue of untreated HIV."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe until the CD4 count falls below 200/mm3 is inappropriate because waiting for the CD4 count to fall is outdated; antiretroviral therapy is recommended for all patients with HIV."
            },
            {
              "id": "B",
              "text": "Option A: Topical nystatin suspension is inappropriate because topical nystatin is used for oral candidiasis, which typically causes removable white plaques; these plaques do not scrape off."
            },
            {
              "id": "C",
              "text": "Option B: Oral fluconazole treats candidiasis, especially with esophageal or refractory disease, but this lesion is not described as thrush."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe until the CD4 count falls below 200/mm3 is inappropriate because waiting for the CD4 count to fall is outdated; antiretroviral therapy is recommended for all patients with HIV."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i012-medicare-hospice-eligibility-duration",
      "expectedHashes": {
        "ranaze_step3_uat": "20eb68f9bb64a388cf53eddfdfaa1f8c41412a03a62edf3ffe43200b4bf88282",
        "ranaze_step3_prd": "20eb68f9bb64a388cf53eddfdfaa1f8c41412a03a62edf3ffe43200b4bf88282"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hospice is unavailable unless he first stops all opioid analgesics is inappropriate because hospice includes aggressive symptom management, including opioid analgesics, rather than requiring their discontinuation."
            },
            {
              "id": "B",
              "text": "Option B: Hospice is available only after the primary physician and an oncologist agree on the exact tumor stage is inappropriate because hospice eligibility does not depend on agreeing on an exact tumor stage; it depends on terminal prognosis and patient goals of care."
            },
            {
              "id": "C",
              "text": "Option C: He can enroll in hospice only if he declines all future hospital care for any reason is inappropriate because hospice patients may still receive certain inpatient care, including short-term inpatient management related to the terminal condition; they are not barred from all hospital care for any reason."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hospice is unavailable unless he first stops all opioid analgesics is inappropriate because hospice includes aggressive symptom management, including opioid analgesics, rather than requiring their discontinuation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hospice is available only after the primary physician and an oncologist agree on the exact tumor stage is inappropriate because hospice eligibility does not depend on agreeing on an exact tumor stage; it depends on terminal prognosis and patient goals of care."
            },
            {
              "id": "B",
              "text": "Option A: Hospice is unavailable unless he first stops all opioid analgesics is inappropriate because hospice includes aggressive symptom management, including opioid analgesics, rather than requiring their discontinuation."
            },
            {
              "id": "C",
              "text": "Option C: He can enroll in hospice only if he declines all future hospital care for any reason is inappropriate because hospice patients may still receive certain inpatient care, including short-term inpatient management related to the terminal condition; they are not barred from all hospital care for any reason."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hospice is available only after the primary physician and an oncologist agree on the exact tumor stage is inappropriate because hospice eligibility does not depend on agreeing on an exact tumor stage; it depends on terminal prognosis and patient goals of care."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He can enroll in hospice only if he declines all future hospital care for any reason is inappropriate because hospice patients may still receive certain inpatient care, including short-term inpatient management related to the terminal condition; they are not barred from all hospital care for any reason."
            },
            {
              "id": "B",
              "text": "Option A: Hospice is unavailable unless he first stops all opioid analgesics is inappropriate because hospice includes aggressive symptom management, including opioid analgesics, rather than requiring their discontinuation."
            },
            {
              "id": "C",
              "text": "Option B: Hospice is available only after the primary physician and an oncologist agree on the exact tumor stage is inappropriate because hospice eligibility does not depend on agreeing on an exact tumor stage; it depends on terminal prognosis and patient goals of care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He can enroll in hospice only if he declines all future hospital care for any reason is inappropriate because hospice patients may still receive certain inpatient care, including short-term inpatient management related to the terminal condition; they are not barred from all hospital care for any reason."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He is not eligible because metastatic cancer must be from an unknown primary site to qualify is inappropriate because hospice eligibility does not require a cancer of unknown primary. Known metastatic cancer with limited prognosis can qualify."
            },
            {
              "id": "B",
              "text": "Option A: Hospice is unavailable unless he first stops all opioid analgesics is inappropriate because hospice includes aggressive symptom management, including opioid analgesics, rather than requiring their discontinuation."
            },
            {
              "id": "C",
              "text": "Option B: Hospice is available only after the primary physician and an oncologist agree on the exact tumor stage is inappropriate because hospice eligibility does not depend on agreeing on an exact tumor stage; it depends on terminal prognosis and patient goals of care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He is not eligible because metastatic cancer must be from an unknown primary site to qualify is inappropriate because hospice eligibility does not require a cancer of unknown primary. Known metastatic cancer with limited prognosis can qualify."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He is eligible only if he first enters a skilled nursing facility is inappropriate because hospice can be provided in multiple settings and does not require prior skilled nursing facility placement."
            },
            {
              "id": "B",
              "text": "Option A: Hospice is unavailable unless he first stops all opioid analgesics is inappropriate because hospice includes aggressive symptom management, including opioid analgesics, rather than requiring their discontinuation."
            },
            {
              "id": "C",
              "text": "Option B: Hospice is available only after the primary physician and an oncologist agree on the exact tumor stage is inappropriate because hospice eligibility does not depend on agreeing on an exact tumor stage; it depends on terminal prognosis and patient goals of care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He is eligible only if he first enters a skilled nursing facility is inappropriate because hospice can be provided in multiple settings and does not require prior skilled nursing facility placement."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He may receive hospice only after pathology confirms a life expectancy under 30 days is inappropriate because a 30-day prognosis is not required; the standard is a terminal illness with an expected course of about 6 months or less."
            },
            {
              "id": "B",
              "text": "Option A: Hospice is unavailable unless he first stops all opioid analgesics is inappropriate because hospice includes aggressive symptom management, including opioid analgesics, rather than requiring their discontinuation."
            },
            {
              "id": "C",
              "text": "Option B: Hospice is available only after the primary physician and an oncologist agree on the exact tumor stage is inappropriate because hospice eligibility does not depend on agreeing on an exact tumor stage; it depends on terminal prognosis and patient goals of care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He may receive hospice only after pathology confirms a life expectancy under 30 days is inappropriate because a 30-day prognosis is not required; the standard is a terminal illness with an expected course of about 6 months or less."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i015-thrombotic-thrombocytopenic-purpura",
      "expectedHashes": {
        "ranaze_step3_uat": "402140db4061eec060e5fba1a11fa567dff2cae2c34d46688b826fd283d4273c",
        "ranaze_step3_prd": "402140db4061eec060e5fba1a11fa567dff2cae2c34d46688b826fd283d4273c"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute immune thrombocytopenia is inappropriate because immune thrombocytopenia causes isolated thrombocytopenia and does not explain schistocytes, hemolytic anemia, neurologic changes, and renal failure."
            },
            {
              "id": "B",
              "text": "Option B: Autoimmune hemolytic anemia can cause anemia and elevated bilirubin, but the direct antiglobulin test is negative and severe thrombocytopenia with schistocytes suggests microangiopathic hemolysis instead."
            },
            {
              "id": "C",
              "text": "Option C: Disseminated intravascular coagulation can cause thrombocytopenia and schistocytes, but PT and PTT are typically prolonged rather than normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute immune thrombocytopenia is inappropriate because immune thrombocytopenia causes isolated thrombocytopenia and does not explain schistocytes, hemolytic anemia, neurologic changes, and renal failure."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Autoimmune hemolytic anemia can cause anemia and elevated bilirubin, but the direct antiglobulin test is negative and severe thrombocytopenia with schistocytes suggests microangiopathic hemolysis instead."
            },
            {
              "id": "B",
              "text": "Option A: Acute immune thrombocytopenia is inappropriate because immune thrombocytopenia causes isolated thrombocytopenia and does not explain schistocytes, hemolytic anemia, neurologic changes, and renal failure."
            },
            {
              "id": "C",
              "text": "Option C: Disseminated intravascular coagulation can cause thrombocytopenia and schistocytes, but PT and PTT are typically prolonged rather than normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Autoimmune hemolytic anemia can cause anemia and elevated bilirubin, but the direct antiglobulin test is negative and severe thrombocytopenia with schistocytes suggests microangiopathic hemolysis instead."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Disseminated intravascular coagulation can cause thrombocytopenia and schistocytes, but PT and PTT are typically prolonged rather than normal."
            },
            {
              "id": "B",
              "text": "Option A: Acute immune thrombocytopenia is inappropriate because immune thrombocytopenia causes isolated thrombocytopenia and does not explain schistocytes, hemolytic anemia, neurologic changes, and renal failure."
            },
            {
              "id": "C",
              "text": "Option B: Autoimmune hemolytic anemia can cause anemia and elevated bilirubin, but the direct antiglobulin test is negative and severe thrombocytopenia with schistocytes suggests microangiopathic hemolysis instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Disseminated intravascular coagulation can cause thrombocytopenia and schistocytes, but PT and PTT are typically prolonged rather than normal."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Heparin-induced thrombocytopenia requires heparin exposure and usually causes thrombosis rather than this full picture of MAHA, neurologic findings, and renal injury."
            },
            {
              "id": "B",
              "text": "Option A: Acute immune thrombocytopenia is inappropriate because immune thrombocytopenia causes isolated thrombocytopenia and does not explain schistocytes, hemolytic anemia, neurologic changes, and renal failure."
            },
            {
              "id": "C",
              "text": "Option B: Autoimmune hemolytic anemia can cause anemia and elevated bilirubin, but the direct antiglobulin test is negative and severe thrombocytopenia with schistocytes suggests microangiopathic hemolysis instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Heparin-induced thrombocytopenia requires heparin exposure and usually causes thrombosis rather than this full picture of MAHA, neurologic findings, and renal injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hemolytic uremic syndrome is another thrombotic microangiopathy but is classically associated with a diarrheal prodrome and is more common in children; this presentation with prominent neurologic symptoms is more typical of TTP."
            },
            {
              "id": "B",
              "text": "Option A: Acute immune thrombocytopenia is inappropriate because immune thrombocytopenia causes isolated thrombocytopenia and does not explain schistocytes, hemolytic anemia, neurologic changes, and renal failure."
            },
            {
              "id": "C",
              "text": "Option B: Autoimmune hemolytic anemia can cause anemia and elevated bilirubin, but the direct antiglobulin test is negative and severe thrombocytopenia with schistocytes suggests microangiopathic hemolysis instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hemolytic uremic syndrome is another thrombotic microangiopathy but is classically associated with a diarrheal prodrome and is more common in children; this presentation with prominent neurologic symptoms is more typical of TTP."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute promyelocytic leukemia often causes DIC and abnormal coagulation studies, and the smear finding here is fragmented red cells rather than blasts or promyelocytes."
            },
            {
              "id": "B",
              "text": "Option A: Acute immune thrombocytopenia is inappropriate because immune thrombocytopenia causes isolated thrombocytopenia and does not explain schistocytes, hemolytic anemia, neurologic changes, and renal failure."
            },
            {
              "id": "C",
              "text": "Option B: Autoimmune hemolytic anemia can cause anemia and elevated bilirubin, but the direct antiglobulin test is negative and severe thrombocytopenia with schistocytes suggests microangiopathic hemolysis instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute promyelocytic leukemia often causes DIC and abnormal coagulation studies, and the smear finding here is fragmented red cells rather than blasts or promyelocytes."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i016-dexa-for-osteoporosis-screening",
      "expectedHashes": {
        "ranaze_step3_uat": "414a84fd92732bc3afdf599aec1d2c5231545a2f80975b22f144988aef2340ac",
        "ranaze_step3_prd": "414a84fd92732bc3afdf599aec1d2c5231545a2f80975b22f144988aef2340ac"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum bone turnover marker panel is inappropriate because bone turnover markers can be used in selected situations to monitor treatment response or adherence, but they do not establish the diagnosis as well as central DEXA."
            },
            {
              "id": "B",
              "text": "Option C: Plain radiographs of the forearms and wrists is inappropriate because plain radiographs are insensitive for early osteoporosis and are not the best screening or diagnostic test for bone density loss."
            },
            {
              "id": "C",
              "text": "Option D: Quantitative ultrasound of the calcaneus is inappropriate because heel ultrasound is not the standard test used to diagnose osteoporosis or guide major treatment decisions when central DEXA is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum bone turnover marker panel is inappropriate because bone turnover markers can be used in selected situations to monitor treatment response or adherence, but they do not establish the diagnosis as well as central DEXA."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plain radiographs of the forearms and wrists is inappropriate because plain radiographs are insensitive for early osteoporosis and are not the best screening or diagnostic test for bone density loss."
            },
            {
              "id": "B",
              "text": "Option A: Serum bone turnover marker panel is inappropriate because bone turnover markers can be used in selected situations to monitor treatment response or adherence, but they do not establish the diagnosis as well as central DEXA."
            },
            {
              "id": "C",
              "text": "Option D: Quantitative ultrasound of the calcaneus is inappropriate because heel ultrasound is not the standard test used to diagnose osteoporosis or guide major treatment decisions when central DEXA is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plain radiographs of the forearms and wrists is inappropriate because plain radiographs are insensitive for early osteoporosis and are not the best screening or diagnostic test for bone density loss."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Quantitative ultrasound of the calcaneus is inappropriate because heel ultrasound is not the standard test used to diagnose osteoporosis or guide major treatment decisions when central DEXA is available."
            },
            {
              "id": "B",
              "text": "Option A: Serum bone turnover marker panel is inappropriate because bone turnover markers can be used in selected situations to monitor treatment response or adherence, but they do not establish the diagnosis as well as central DEXA."
            },
            {
              "id": "C",
              "text": "Option C: Plain radiographs of the forearms and wrists is inappropriate because plain radiographs are insensitive for early osteoporosis and are not the best screening or diagnostic test for bone density loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Quantitative ultrasound of the calcaneus is inappropriate because heel ultrasound is not the standard test used to diagnose osteoporosis or guide major treatment decisions when central DEXA is available."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radionuclide whole-body bone scan is inappropriate because bone scan is used for selected focal osseous processes such as metastases or occult fractures, not routine osteoporosis diagnosis."
            },
            {
              "id": "B",
              "text": "Option A: Serum bone turnover marker panel is inappropriate because bone turnover markers can be used in selected situations to monitor treatment response or adherence, but they do not establish the diagnosis as well as central DEXA."
            },
            {
              "id": "C",
              "text": "Option C: Plain radiographs of the forearms and wrists is inappropriate because plain radiographs are insensitive for early osteoporosis and are not the best screening or diagnostic test for bone density loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radionuclide whole-body bone scan is inappropriate because bone scan is used for selected focal osseous processes such as metastases or occult fractures, not routine osteoporosis diagnosis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum and urine protein electrophoresis is inappropriate because protein electrophoresis is appropriate when multiple myeloma is suspected, which is not suggested here."
            },
            {
              "id": "B",
              "text": "Option A: Serum bone turnover marker panel is inappropriate because bone turnover markers can be used in selected situations to monitor treatment response or adherence, but they do not establish the diagnosis as well as central DEXA."
            },
            {
              "id": "C",
              "text": "Option C: Plain radiographs of the forearms and wrists is inappropriate because plain radiographs are insensitive for early osteoporosis and are not the best screening or diagnostic test for bone density loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum and urine protein electrophoresis is inappropriate because protein electrophoresis is appropriate when multiple myeloma is suspected, which is not suggested here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thoracolumbar vertebral fracture assessment radiographs is inappropriate because vertebral imaging is useful when occult vertebral compression fracture is suspected, but it does not replace central DEXA as the primary diagnostic study for osteoporosis."
            },
            {
              "id": "B",
              "text": "Option A: Serum bone turnover marker panel is inappropriate because bone turnover markers can be used in selected situations to monitor treatment response or adherence, but they do not establish the diagnosis as well as central DEXA."
            },
            {
              "id": "C",
              "text": "Option C: Plain radiographs of the forearms and wrists is inappropriate because plain radiographs are insensitive for early osteoporosis and are not the best screening or diagnostic test for bone density loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thoracolumbar vertebral fracture assessment radiographs is inappropriate because vertebral imaging is useful when occult vertebral compression fracture is suspected, but it does not replace central DEXA as the primary diagnostic study for osteoporosis."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i020-eclampsia-magnesium-toxicity-reflex-loss",
      "expectedHashes": {
        "ranaze_step3_uat": "d3375d61c25b6fd75f4a5c263f9a8496bcfb927a8bffa250f63f44ddff4bc3ad",
        "ranaze_step3_prd": "d3375d61c25b6fd75f4a5c263f9a8496bcfb927a8bffa250f63f44ddff4bc3ad"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bilateral basilar crackles is inappropriate because pulmonary crackles suggest fluid overload or pulmonary edema, which can coexist in severe preeclampsia but are not the most specific sign of magnesium toxicity."
            },
            {
              "id": "B",
              "text": "Option B: Blood pressure lower than on admission is inappropriate because lower blood pressure reflects treatment response and does not specifically identify magnesium excess as the cause of somnolence."
            },
            {
              "id": "C",
              "text": "Option D: Minimal fetal heart rate variability can occur with maternal magnesium exposure but is less specific than reflex loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bilateral basilar crackles is inappropriate because pulmonary crackles suggest fluid overload or pulmonary edema, which can coexist in severe preeclampsia but are not the most specific sign of magnesium toxicity."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Blood pressure lower than on admission is inappropriate because lower blood pressure reflects treatment response and does not specifically identify magnesium excess as the cause of somnolence."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral basilar crackles is inappropriate because pulmonary crackles suggest fluid overload or pulmonary edema, which can coexist in severe preeclampsia but are not the most specific sign of magnesium toxicity."
            },
            {
              "id": "C",
              "text": "Option D: Minimal fetal heart rate variability can occur with maternal magnesium exposure but is less specific than reflex loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Blood pressure lower than on admission is inappropriate because lower blood pressure reflects treatment response and does not specifically identify magnesium excess as the cause of somnolence."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Minimal fetal heart rate variability can occur with maternal magnesium exposure but is less specific than reflex loss."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral basilar crackles is inappropriate because pulmonary crackles suggest fluid overload or pulmonary edema, which can coexist in severe preeclampsia but are not the most specific sign of magnesium toxicity."
            },
            {
              "id": "C",
              "text": "Option B: Blood pressure lower than on admission is inappropriate because lower blood pressure reflects treatment response and does not specifically identify magnesium excess as the cause of somnolence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Minimal fetal heart rate variability can occur with maternal magnesium exposure but is less specific than reflex loss."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Respiratory rate of 10/min is inappropriate because respiratory depression can occur with magnesium toxicity, but absent reflexes are the earlier and more specific bedside finding."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral basilar crackles is inappropriate because pulmonary crackles suggest fluid overload or pulmonary edema, which can coexist in severe preeclampsia but are not the most specific sign of magnesium toxicity."
            },
            {
              "id": "C",
              "text": "Option B: Blood pressure lower than on admission is inappropriate because lower blood pressure reflects treatment response and does not specifically identify magnesium excess as the cause of somnolence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Respiratory rate of 10/min is inappropriate because respiratory depression can occur with magnesium toxicity, but absent reflexes are the earlier and more specific bedside finding."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urine output of 90 mL over 6 hours is inappropriate because low urine output increases the risk of magnesium accumulation because magnesium is renally cleared, but oliguria is a risk factor rather than the most specific toxic manifestation."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral basilar crackles is inappropriate because pulmonary crackles suggest fluid overload or pulmonary edema, which can coexist in severe preeclampsia but are not the most specific sign of magnesium toxicity."
            },
            {
              "id": "C",
              "text": "Option B: Blood pressure lower than on admission is inappropriate because lower blood pressure reflects treatment response and does not specifically identify magnesium excess as the cause of somnolence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urine output of 90 mL over 6 hours is inappropriate because low urine output increases the risk of magnesium accumulation because magnesium is renally cleared, but oliguria is a risk factor rather than the most specific toxic manifestation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cervix now 6 cm dilated is inappropriate because cervical dilation reflects labor progress and does not explain the patient\u0027s somnolence."
            },
            {
              "id": "B",
              "text": "Option A: Bilateral basilar crackles is inappropriate because pulmonary crackles suggest fluid overload or pulmonary edema, which can coexist in severe preeclampsia but are not the most specific sign of magnesium toxicity."
            },
            {
              "id": "C",
              "text": "Option B: Blood pressure lower than on admission is inappropriate because lower blood pressure reflects treatment response and does not specifically identify magnesium excess as the cause of somnolence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cervix now 6 cm dilated is inappropriate because cervical dilation reflects labor progress and does not explain the patient\u0027s somnolence."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i022-pregnancy-graves-first-trimester",
      "expectedHashes": {
        "ranaze_step3_uat": "3c957e1f8a2269ee4e3d16bfacfbd7b9a27807cc6b38ea7cf2ac513d81fffbd5",
        "ranaze_step3_prd": "3c957e1f8a2269ee4e3d16bfacfbd7b9a27807cc6b38ea7cf2ac513d81fffbd5"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin methimazole therapy is inappropriate because methimazole is effective for hyperthyroidism but is not the preferred first-line thionamide in the first trimester when PTU is favored."
            },
            {
              "id": "B",
              "text": "Option C: Schedule radioiodine ablation is inappropriate because radioiodine is contraindicated in pregnancy because fetal thyroid tissue can be damaged."
            },
            {
              "id": "C",
              "text": "Option D: Repeat thyroid studies after delivery without treatment is inappropriate because deferring treatment is inappropriate because she has biochemical and clinical evidence of overt hyperthyroidism, which increases maternal and fetal risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin methimazole therapy is inappropriate because methimazole is effective for hyperthyroidism but is not the preferred first-line thionamide in the first trimester when PTU is favored."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule radioiodine ablation is inappropriate because radioiodine is contraindicated in pregnancy because fetal thyroid tissue can be damaged."
            },
            {
              "id": "B",
              "text": "Option A: Begin methimazole therapy is inappropriate because methimazole is effective for hyperthyroidism but is not the preferred first-line thionamide in the first trimester when PTU is favored."
            },
            {
              "id": "C",
              "text": "Option D: Repeat thyroid studies after delivery without treatment is inappropriate because deferring treatment is inappropriate because she has biochemical and clinical evidence of overt hyperthyroidism, which increases maternal and fetal risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule radioiodine ablation is inappropriate because radioiodine is contraindicated in pregnancy because fetal thyroid tissue can be damaged."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat thyroid studies after delivery without treatment is inappropriate because deferring treatment is inappropriate because she has biochemical and clinical evidence of overt hyperthyroidism, which increases maternal and fetal risk."
            },
            {
              "id": "B",
              "text": "Option A: Begin methimazole therapy is inappropriate because methimazole is effective for hyperthyroidism but is not the preferred first-line thionamide in the first trimester when PTU is favored."
            },
            {
              "id": "C",
              "text": "Option C: Schedule radioiodine ablation is inappropriate because radioiodine is contraindicated in pregnancy because fetal thyroid tissue can be damaged."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat thyroid studies after delivery without treatment is inappropriate because deferring treatment is inappropriate because she has biochemical and clinical evidence of overt hyperthyroidism, which increases maternal and fetal risk."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start propranolol alone and defer antithyroid therapy is inappropriate because a beta blocker can help symptoms briefly, but antithyroid treatment is still needed for overt disease."
            },
            {
              "id": "B",
              "text": "Option A: Begin methimazole therapy is inappropriate because methimazole is effective for hyperthyroidism but is not the preferred first-line thionamide in the first trimester when PTU is favored."
            },
            {
              "id": "C",
              "text": "Option C: Schedule radioiodine ablation is inappropriate because radioiodine is contraindicated in pregnancy because fetal thyroid tissue can be damaged."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start propranolol alone and defer antithyroid therapy is inappropriate because a beta blocker can help symptoms briefly, but antithyroid treatment is still needed for overt disease."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed with subtotal thyroidectomy now is inappropriate because surgery is reserved for selected patients who cannot use antithyroid drugs or have other compelling indications; it is not the best next step here."
            },
            {
              "id": "B",
              "text": "Option A: Begin methimazole therapy is inappropriate because methimazole is effective for hyperthyroidism but is not the preferred first-line thionamide in the first trimester when PTU is favored."
            },
            {
              "id": "C",
              "text": "Option C: Schedule radioiodine ablation is inappropriate because radioiodine is contraindicated in pregnancy because fetal thyroid tissue can be damaged."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed with subtotal thyroidectomy now is inappropriate because surgery is reserved for selected patients who cannot use antithyroid drugs or have other compelling indications; it is not the best next step here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recheck TSH in 3 months because early pregnancy lowers TSH physiologically is inappropriate because tSH can fall physiologically in early pregnancy, but a markedly elevated free T4 with clear symptoms indicates true hyperthyroidism rather than normal gestational change."
            },
            {
              "id": "B",
              "text": "Option A: Begin methimazole therapy is inappropriate because methimazole is effective for hyperthyroidism but is not the preferred first-line thionamide in the first trimester when PTU is favored."
            },
            {
              "id": "C",
              "text": "Option C: Schedule radioiodine ablation is inappropriate because radioiodine is contraindicated in pregnancy because fetal thyroid tissue can be damaged."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recheck TSH in 3 months because early pregnancy lowers TSH physiologically is inappropriate because tSH can fall physiologically in early pregnancy, but a markedly elevated free T4 with clear symptoms indicates true hyperthyroidism rather than normal gestational change."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i028-somatic-symptoms-school-stress",
      "expectedHashes": {
        "ranaze_step3_uat": "e33a7b579772c2e1d2ab53cf28e69a49077c1db5daaf7433634bc6ec07a4f29a",
        "ranaze_step3_prd": "e33a7b579772c2e1d2ab53cf28e69a49077c1db5daaf7433634bc6ec07a4f29a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Has anyone in the family had similar complaints\u0022 is inappropriate because incorrect because family history may be explored later, but it does not address the mother\u0027s immediate question as effectively as linking symptoms to stress in a validating way."
            },
            {
              "id": "B",
              "text": "Option B: \u0022Has the school threatened consequences because of the absences\u0022 is inappropriate because incorrect because school consequences may matter for planning, but this response misses the key opportunity to frame the symptoms constructively."
            },
            {
              "id": "C",
              "text": "Option C: \u0022I cannot support school absences unless he has fever or vomiting.\u0022 is inappropriate because incorrect because a punitive statement increases conflict and does not help the family understand the likely mechanism of the symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Has anyone in the family had similar complaints\u0022 is inappropriate because incorrect because family history may be explored later, but it does not address the mother\u0027s immediate question as effectively as linking symptoms to stress in a validating way."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Has the school threatened consequences because of the absences\u0022 is inappropriate because incorrect because school consequences may matter for planning, but this response misses the key opportunity to frame the symptoms constructively."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Has anyone in the family had similar complaints\u0022 is inappropriate because incorrect because family history may be explored later, but it does not address the mother\u0027s immediate question as effectively as linking symptoms to stress in a validating way."
            },
            {
              "id": "C",
              "text": "Option C: \u0022I cannot support school absences unless he has fever or vomiting.\u0022 is inappropriate because incorrect because a punitive statement increases conflict and does not help the family understand the likely mechanism of the symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Has the school threatened consequences because of the absences\u0022 is inappropriate because incorrect because school consequences may matter for planning, but this response misses the key opportunity to frame the symptoms constructively."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I cannot support school absences unless he has fever or vomiting.\u0022 is inappropriate because incorrect because a punitive statement increases conflict and does not help the family understand the likely mechanism of the symptoms."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Has anyone in the family had similar complaints\u0022 is inappropriate because incorrect because family history may be explored later, but it does not address the mother\u0027s immediate question as effectively as linking symptoms to stress in a validating way."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has the school threatened consequences because of the absences\u0022 is inappropriate because incorrect because school consequences may matter for planning, but this response misses the key opportunity to frame the symptoms constructively."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I cannot support school absences unless he has fever or vomiting.\u0022 is inappropriate because incorrect because a punitive statement increases conflict and does not help the family understand the likely mechanism of the symptoms."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022We should arrange a neurologic scan before discussing school.\u0022 is inappropriate because incorrect because the history suggests a functional pattern with repeated unrevealing evaluations, so immediately escalating testing is not the most appropriate response."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Has anyone in the family had similar complaints\u0022 is inappropriate because incorrect because family history may be explored later, but it does not address the mother\u0027s immediate question as effectively as linking symptoms to stress in a validating way."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has the school threatened consequences because of the absences\u0022 is inappropriate because incorrect because school consequences may matter for planning, but this response misses the key opportunity to frame the symptoms constructively."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022We should arrange a neurologic scan before discussing school.\u0022 is inappropriate because incorrect because the history suggests a functional pattern with repeated unrevealing evaluations, so immediately escalating testing is not the most appropriate response."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I do not know him well enough yet to comment on school placement.\u0022 is inappropriate because incorrect because deferring guidance is less helpful than beginning to explain the likely relationship between stress and symptoms."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Has anyone in the family had similar complaints\u0022 is inappropriate because incorrect because family history may be explored later, but it does not address the mother\u0027s immediate question as effectively as linking symptoms to stress in a validating way."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has the school threatened consequences because of the absences\u0022 is inappropriate because incorrect because school consequences may matter for planning, but this response misses the key opportunity to frame the symptoms constructively."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I do not know him well enough yet to comment on school placement.\u0022 is inappropriate because incorrect because deferring guidance is less helpful than beginning to explain the likely relationship between stress and symptoms."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022He should stay home until these symptoms completely stop.\u0022 is inappropriate because incorrect because reinforcing avoidance can worsen functional impairment and school refusal."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Has anyone in the family had similar complaints\u0022 is inappropriate because incorrect because family history may be explored later, but it does not address the mother\u0027s immediate question as effectively as linking symptoms to stress in a validating way."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Has the school threatened consequences because of the absences\u0022 is inappropriate because incorrect because school consequences may matter for planning, but this response misses the key opportunity to frame the symptoms constructively."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022He should stay home until these symptoms completely stop.\u0022 is inappropriate because incorrect because reinforcing avoidance can worsen functional impairment and school refusal."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i032-hfref-crt-upgrade",
      "expectedHashes": {
        "ranaze_step3_uat": "a78627d3cb23ccc9d536ff685bfcc115bf40bd4d3ad03902645915cb0e8c7f09",
        "ranaze_step3_prd": "a78627d3cb23ccc9d536ff685bfcc115bf40bd4d3ad03902645915cb0e8c7f09"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Add digoxin is inappropriate because digoxin can reduce heart-failure hospitalizations in selected patients but does not improve survival and is not the best next step here."
            },
            {
              "id": "B",
              "text": "Option B: Add hydralazine and isosorbide dinitrate is inappropriate because hydralazine and isosorbide dinitrate is useful in specific circumstances, especially when RAAS inhibition cannot be used or as selected adjunctive therapy, but it is not the best next intervention in this patient with marked electrical dyssynchrony."
            },
            {
              "id": "C",
              "text": "Option C: Add ivabradine is inappropriate because ivabradine is considered for symptomatic HFrEF in sinus rhythm when resting heart rate remains elevated despite maximally tolerated beta-blocker therapy; that threshold is not met here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Add digoxin is inappropriate because digoxin can reduce heart-failure hospitalizations in selected patients but does not improve survival and is not the best next step here."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Add hydralazine and isosorbide dinitrate is inappropriate because hydralazine and isosorbide dinitrate is useful in specific circumstances, especially when RAAS inhibition cannot be used or as selected adjunctive therapy, but it is not the best next intervention in this patient with marked electrical dyssynchrony."
            },
            {
              "id": "B",
              "text": "Option A: Add digoxin is inappropriate because digoxin can reduce heart-failure hospitalizations in selected patients but does not improve survival and is not the best next step here."
            },
            {
              "id": "C",
              "text": "Option C: Add ivabradine is inappropriate because ivabradine is considered for symptomatic HFrEF in sinus rhythm when resting heart rate remains elevated despite maximally tolerated beta-blocker therapy; that threshold is not met here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Add hydralazine and isosorbide dinitrate is inappropriate because hydralazine and isosorbide dinitrate is useful in specific circumstances, especially when RAAS inhibition cannot be used or as selected adjunctive therapy, but it is not the best next intervention in this patient with marked electrical dyssynchrony."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Add ivabradine is inappropriate because ivabradine is considered for symptomatic HFrEF in sinus rhythm when resting heart rate remains elevated despite maximally tolerated beta-blocker therapy; that threshold is not met here."
            },
            {
              "id": "B",
              "text": "Option A: Add digoxin is inappropriate because digoxin can reduce heart-failure hospitalizations in selected patients but does not improve survival and is not the best next step here."
            },
            {
              "id": "C",
              "text": "Option B: Add hydralazine and isosorbide dinitrate is inappropriate because hydralazine and isosorbide dinitrate is useful in specific circumstances, especially when RAAS inhibition cannot be used or as selected adjunctive therapy, but it is not the best next intervention in this patient with marked electrical dyssynchrony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Add ivabradine is inappropriate because ivabradine is considered for symptomatic HFrEF in sinus rhythm when resting heart rate remains elevated despite maximally tolerated beta-blocker therapy; that threshold is not met here."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase the torsemide maintenance dose is inappropriate because increasing loop diuretic dose may help congestion symptoms but does not improve mortality and is not the key next disease-modifying step."
            },
            {
              "id": "B",
              "text": "Option A: Add digoxin is inappropriate because digoxin can reduce heart-failure hospitalizations in selected patients but does not improve survival and is not the best next step here."
            },
            {
              "id": "C",
              "text": "Option B: Add hydralazine and isosorbide dinitrate is inappropriate because hydralazine and isosorbide dinitrate is useful in specific circumstances, especially when RAAS inhibition cannot be used or as selected adjunctive therapy, but it is not the best next intervention in this patient with marked electrical dyssynchrony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase the torsemide maintenance dose is inappropriate because increasing loop diuretic dose may help congestion symptoms but does not improve mortality and is not the key next disease-modifying step."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer for durable left ventricular assist device evaluation is inappropriate because durable LVAD is reserved for advanced refractory heart failure with severe functional limitation, recurrent decompensation, or end-organ compromise; that threshold is not described here."
            },
            {
              "id": "B",
              "text": "Option A: Add digoxin is inappropriate because digoxin can reduce heart-failure hospitalizations in selected patients but does not improve survival and is not the best next step here."
            },
            {
              "id": "C",
              "text": "Option B: Add hydralazine and isosorbide dinitrate is inappropriate because hydralazine and isosorbide dinitrate is useful in specific circumstances, especially when RAAS inhibition cannot be used or as selected adjunctive therapy, but it is not the best next intervention in this patient with marked electrical dyssynchrony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer for durable left ventricular assist device evaluation is inappropriate because durable LVAD is reserved for advanced refractory heart failure with severe functional limitation, recurrent decompensation, or end-organ compromise; that threshold is not described here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start vericiguat is inappropriate because vericiguat is used after recent worsening heart failure in selected high-risk patients, not as the best next step for this stable outpatient whose major actionable issue is electrical dyssynchrony."
            },
            {
              "id": "B",
              "text": "Option A: Add digoxin is inappropriate because digoxin can reduce heart-failure hospitalizations in selected patients but does not improve survival and is not the best next step here."
            },
            {
              "id": "C",
              "text": "Option B: Add hydralazine and isosorbide dinitrate is inappropriate because hydralazine and isosorbide dinitrate is useful in specific circumstances, especially when RAAS inhibition cannot be used or as selected adjunctive therapy, but it is not the best next intervention in this patient with marked electrical dyssynchrony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start vericiguat is inappropriate because vericiguat is used after recent worsening heart failure in selected high-risk patients, not as the best next step for this stable outpatient whose major actionable issue is electrical dyssynchrony."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i034-point-source-outbreak",
      "expectedHashes": {
        "ranaze_step3_uat": "b70ca936f5fd3fb0e020472188754b554f9f4684443017fd849f057564af8f1b",
        "ranaze_step3_prd": "b70ca936f5fd3fb0e020472188754b554f9f4684443017fd849f057564af8f1b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Several ill attendees work in the same accounting department is inappropriate because shared workplace membership can explain why people were present together, but it does not establish the exposure pattern that defines a point-source outbreak."
            },
            {
              "id": "B",
              "text": "Option B: Stool testing from 4 patients identifies norovirus is inappropriate because identifying a pathogen helps with diagnosis and control measures, but organism identity alone does not distinguish point-source from propagated spread."
            },
            {
              "id": "C",
              "text": "Option D: The banquet hall had a refrigeration citation 2 years ago is inappropriate because a remote inspection history may raise suspicion about food handling but does not characterize the outbreak pattern itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Several ill attendees work in the same accounting department is inappropriate because shared workplace membership can explain why people were present together, but it does not establish the exposure pattern that defines a point-source outbreak."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stool testing from 4 patients identifies norovirus is inappropriate because identifying a pathogen helps with diagnosis and control measures, but organism identity alone does not distinguish point-source from propagated spread."
            },
            {
              "id": "B",
              "text": "Option A: Several ill attendees work in the same accounting department is inappropriate because shared workplace membership can explain why people were present together, but it does not establish the exposure pattern that defines a point-source outbreak."
            },
            {
              "id": "C",
              "text": "Option D: The banquet hall had a refrigeration citation 2 years ago is inappropriate because a remote inspection history may raise suspicion about food handling but does not characterize the outbreak pattern itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stool testing from 4 patients identifies norovirus is inappropriate because identifying a pathogen helps with diagnosis and control measures, but organism identity alone does not distinguish point-source from propagated spread."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The banquet hall had a refrigeration citation 2 years ago is inappropriate because a remote inspection history may raise suspicion about food handling but does not characterize the outbreak pattern itself."
            },
            {
              "id": "B",
              "text": "Option A: Several ill attendees work in the same accounting department is inappropriate because shared workplace membership can explain why people were present together, but it does not establish the exposure pattern that defines a point-source outbreak."
            },
            {
              "id": "C",
              "text": "Option B: Stool testing from 4 patients identifies norovirus is inappropriate because identifying a pathogen helps with diagnosis and control measures, but organism identity alone does not distinguish point-source from propagated spread."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The banquet hall had a refrigeration citation 2 years ago is inappropriate because a remote inspection history may raise suspicion about food handling but does not characterize the outbreak pattern itself."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Two household contacts became ill 3 days after caring for sick attendees at home is inappropriate because later illness among household contacts suggests secondary transmission, which argues for propagated spread rather than a single exposure event."
            },
            {
              "id": "B",
              "text": "Option A: Several ill attendees work in the same accounting department is inappropriate because shared workplace membership can explain why people were present together, but it does not establish the exposure pattern that defines a point-source outbreak."
            },
            {
              "id": "C",
              "text": "Option B: Stool testing from 4 patients identifies norovirus is inappropriate because identifying a pathogen helps with diagnosis and control measures, but organism identity alone does not distinguish point-source from propagated spread."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Two household contacts became ill 3 days after caring for sick attendees at home is inappropriate because later illness among household contacts suggests secondary transmission, which argues for propagated spread rather than a single exposure event."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Illness was more common among attendees who ate the egg-salad appetizer than among those who did not is inappropriate because a food-specific attack-rate difference can identify a likely vehicle, but onset clustering across cases is the stronger hallmark of point-source spread."
            },
            {
              "id": "B",
              "text": "Option A: Several ill attendees work in the same accounting department is inappropriate because shared workplace membership can explain why people were present together, but it does not establish the exposure pattern that defines a point-source outbreak."
            },
            {
              "id": "C",
              "text": "Option B: Stool testing from 4 patients identifies norovirus is inappropriate because identifying a pathogen helps with diagnosis and control measures, but organism identity alone does not distinguish point-source from propagated spread."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Illness was more common among attendees who ate the egg-salad appetizer than among those who did not is inappropriate because a food-specific attack-rate difference can identify a likely vehicle, but onset clustering across cases is the stronger hallmark of point-source spread."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "One server reported having diarrhea during the week before the luncheon is inappropriate because an ill food handler may be relevant as a source, but that fact alone does not define the temporal pattern of a point-source outbreak."
            },
            {
              "id": "B",
              "text": "Option A: Several ill attendees work in the same accounting department is inappropriate because shared workplace membership can explain why people were present together, but it does not establish the exposure pattern that defines a point-source outbreak."
            },
            {
              "id": "C",
              "text": "Option B: Stool testing from 4 patients identifies norovirus is inappropriate because identifying a pathogen helps with diagnosis and control measures, but organism identity alone does not distinguish point-source from propagated spread."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "One server reported having diarrhea during the week before the luncheon is inappropriate because an ill food handler may be relevant as a source, but that fact alone does not define the temporal pattern of a point-source outbreak."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i037-pregnancy-renal-colic-analgesia",
      "expectedHashes": {
        "ranaze_step3_uat": "ccccb5d1165818a7bfc9a1f44883de71a5904529fe0da78e1d6c254161a88aa6",
        "ranaze_step3_prd": "ccccb5d1165818a7bfc9a1f44883de71a5904529fe0da78e1d6c254161a88aa6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral ibuprofen as needed is inappropriate because nSAIDs such as ibuprofen are generally avoided in pregnancy, especially as gestation advances, because of fetal renal and ductal risks."
            },
            {
              "id": "B",
              "text": "Option B: IV ketorolac is inappropriate because ketorolac is an NSAID and is not the preferred analgesic for renal colic during pregnancy."
            },
            {
              "id": "C",
              "text": "Option D: Additional acetaminophen only, even if severe pain persists is inappropriate because acetaminophen alone is safe but may be insufficient for severe renal colic; persistent uncontrolled pain warrants stronger pregnancy-compatible analgesia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral ibuprofen as needed is inappropriate because nSAIDs such as ibuprofen are generally avoided in pregnancy, especially as gestation advances, because of fetal renal and ductal risks."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IV ketorolac is inappropriate because ketorolac is an NSAID and is not the preferred analgesic for renal colic during pregnancy."
            },
            {
              "id": "B",
              "text": "Option A: Oral ibuprofen as needed is inappropriate because nSAIDs such as ibuprofen are generally avoided in pregnancy, especially as gestation advances, because of fetal renal and ductal risks."
            },
            {
              "id": "C",
              "text": "Option D: Additional acetaminophen only, even if severe pain persists is inappropriate because acetaminophen alone is safe but may be insufficient for severe renal colic; persistent uncontrolled pain warrants stronger pregnancy-compatible analgesia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IV ketorolac is inappropriate because ketorolac is an NSAID and is not the preferred analgesic for renal colic during pregnancy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Additional acetaminophen only, even if severe pain persists is inappropriate because acetaminophen alone is safe but may be insufficient for severe renal colic; persistent uncontrolled pain warrants stronger pregnancy-compatible analgesia."
            },
            {
              "id": "B",
              "text": "Option A: Oral ibuprofen as needed is inappropriate because nSAIDs such as ibuprofen are generally avoided in pregnancy, especially as gestation advances, because of fetal renal and ductal risks."
            },
            {
              "id": "C",
              "text": "Option B: IV ketorolac is inappropriate because ketorolac is an NSAID and is not the preferred analgesic for renal colic during pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Additional acetaminophen only, even if severe pain persists is inappropriate because acetaminophen alone is safe but may be insufficient for severe renal colic; persistent uncontrolled pain warrants stronger pregnancy-compatible analgesia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical lidocaine patch to the flank is inappropriate because a lidocaine patch is not an effective primary treatment for visceral ureteral colic."
            },
            {
              "id": "B",
              "text": "Option A: Oral ibuprofen as needed is inappropriate because nSAIDs such as ibuprofen are generally avoided in pregnancy, especially as gestation advances, because of fetal renal and ductal risks."
            },
            {
              "id": "C",
              "text": "Option B: IV ketorolac is inappropriate because ketorolac is an NSAID and is not the preferred analgesic for renal colic during pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical lidocaine patch to the flank is inappropriate because a lidocaine patch is not an effective primary treatment for visceral ureteral colic."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tamsulosin without any analgesic medication is inappropriate because medical expulsive therapy does not replace pain control, and symptom relief is needed now."
            },
            {
              "id": "B",
              "text": "Option A: Oral ibuprofen as needed is inappropriate because nSAIDs such as ibuprofen are generally avoided in pregnancy, especially as gestation advances, because of fetal renal and ductal risks."
            },
            {
              "id": "C",
              "text": "Option B: IV ketorolac is inappropriate because ketorolac is an NSAID and is not the preferred analgesic for renal colic during pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tamsulosin without any analgesic medication is inappropriate because medical expulsive therapy does not replace pain control, and symptom relief is needed now."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No analgesia until stone passage is documented is inappropriate because pregnant patients with confirmed renal colic should still receive appropriate analgesia; withholding pain treatment is not appropriate."
            },
            {
              "id": "B",
              "text": "Option A: Oral ibuprofen as needed is inappropriate because nSAIDs such as ibuprofen are generally avoided in pregnancy, especially as gestation advances, because of fetal renal and ductal risks."
            },
            {
              "id": "C",
              "text": "Option B: IV ketorolac is inappropriate because ketorolac is an NSAID and is not the preferred analgesic for renal colic during pregnancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No analgesia until stone passage is documented is inappropriate because pregnant patients with confirmed renal colic should still receive appropriate analgesia; withholding pain treatment is not appropriate."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i038-hypertensive-hemorrhagic-stroke-bp-control",
      "expectedHashes": {
        "ranaze_step3_uat": "1032c0468727411d84d6ec327aca0ddd019813d4194b56586e100cefeca8edd6",
        "ranaze_step3_prd": "1032c0468727411d84d6ec327aca0ddd019813d4194b56586e100cefeca8edd6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer IV dexamethasone is inappropriate because dexamethasone is not routine treatment for hypertensive intracerebral hemorrhage and does not address the immediate priority here."
            },
            {
              "id": "B",
              "text": "Option C: Administer IV tenecteplase is inappropriate because thrombolysis is contraindicated when intracranial hemorrhage is present on imaging."
            },
            {
              "id": "C",
              "text": "Option D: Start prophylactic IV levetiracetam is inappropriate because routine seizure prophylaxis is not indicated for a deep intracerebral hemorrhage without seizures and is not the immediate priority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer IV dexamethasone is inappropriate because dexamethasone is not routine treatment for hypertensive intracerebral hemorrhage and does not address the immediate priority here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer IV tenecteplase is inappropriate because thrombolysis is contraindicated when intracranial hemorrhage is present on imaging."
            },
            {
              "id": "B",
              "text": "Option A: Administer IV dexamethasone is inappropriate because dexamethasone is not routine treatment for hypertensive intracerebral hemorrhage and does not address the immediate priority here."
            },
            {
              "id": "C",
              "text": "Option D: Start prophylactic IV levetiracetam is inappropriate because routine seizure prophylaxis is not indicated for a deep intracerebral hemorrhage without seizures and is not the immediate priority."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer IV tenecteplase is inappropriate because thrombolysis is contraindicated when intracranial hemorrhage is present on imaging."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start prophylactic IV levetiracetam is inappropriate because routine seizure prophylaxis is not indicated for a deep intracerebral hemorrhage without seizures and is not the immediate priority."
            },
            {
              "id": "B",
              "text": "Option A: Administer IV dexamethasone is inappropriate because dexamethasone is not routine treatment for hypertensive intracerebral hemorrhage and does not address the immediate priority here."
            },
            {
              "id": "C",
              "text": "Option C: Administer IV tenecteplase is inappropriate because thrombolysis is contraindicated when intracranial hemorrhage is present on imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start prophylactic IV levetiracetam is inappropriate because routine seizure prophylaxis is not indicated for a deep intracerebral hemorrhage without seizures and is not the immediate priority."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give a mannitol bolus is inappropriate because mannitol is reserved for elevated intracranial pressure or herniation concerns, which are not described here."
            },
            {
              "id": "B",
              "text": "Option A: Administer IV dexamethasone is inappropriate because dexamethasone is not routine treatment for hypertensive intracerebral hemorrhage and does not address the immediate priority here."
            },
            {
              "id": "C",
              "text": "Option C: Administer IV tenecteplase is inappropriate because thrombolysis is contraindicated when intracranial hemorrhage is present on imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give a mannitol bolus is inappropriate because mannitol is reserved for elevated intracranial pressure or herniation concerns, which are not described here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain CT angiography of the head and neck before treating blood pressure is inappropriate because further vascular imaging may be considered selectively, but immediate blood pressure control should not be delayed in this clearly hypertensive hemorrhage."
            },
            {
              "id": "B",
              "text": "Option A: Administer IV dexamethasone is inappropriate because dexamethasone is not routine treatment for hypertensive intracerebral hemorrhage and does not address the immediate priority here."
            },
            {
              "id": "C",
              "text": "Option C: Administer IV tenecteplase is inappropriate because thrombolysis is contraindicated when intracranial hemorrhage is present on imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain CT angiography of the head and neck before treating blood pressure is inappropriate because further vascular imaging may be considered selectively, but immediate blood pressure control should not be delayed in this clearly hypertensive hemorrhage."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give oral aspirin is inappropriate because antiplatelet therapy can worsen bleeding and is contraindicated in an acute intracerebral hemorrhage."
            },
            {
              "id": "B",
              "text": "Option A: Administer IV dexamethasone is inappropriate because dexamethasone is not routine treatment for hypertensive intracerebral hemorrhage and does not address the immediate priority here."
            },
            {
              "id": "C",
              "text": "Option C: Administer IV tenecteplase is inappropriate because thrombolysis is contraindicated when intracranial hemorrhage is present on imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give oral aspirin is inappropriate because antiplatelet therapy can worsen bleeding and is contraindicated in an acute intracerebral hemorrhage."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i039-vomiting-metabolic-alkalosis",
      "expectedHashes": {
        "ranaze_step3_uat": "6d6925743d7352fa8bc7119ac2bdf4862b619923f28d00989b3b650b8bcab28f",
        "ranaze_step3_prd": "6d6925743d7352fa8bc7119ac2bdf4862b619923f28d00989b3b650b8bcab28f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "pH 7.28, Pco2 30 mm Hg, HCO3- 14 mEq/L is inappropriate because this is a primary metabolic acidosis with respiratory compensation, which does not match the elevated serum bicarbonate after prolonged gastric fluid loss."
            },
            {
              "id": "B",
              "text": "Option B: pH 7.33, Pco2 60 mm Hg, HCO3- 31 mEq/L is inappropriate because this pattern suggests primary respiratory acidosis rather than metabolic alkalosis from chloride and hydrogen loss."
            },
            {
              "id": "C",
              "text": "Option C: pH 7.40, Pco2 40 mm Hg, HCO3- 24 mEq/L is inappropriate because a normal arterial blood gas would not fit the marked hypochloremia, hypokalemia, and elevated serum bicarbonate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "pH 7.28, Pco2 30 mm Hg, HCO3- 14 mEq/L is inappropriate because this is a primary metabolic acidosis with respiratory compensation, which does not match the elevated serum bicarbonate after prolonged gastric fluid loss."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "pH 7.33, Pco2 60 mm Hg, HCO3- 31 mEq/L is inappropriate because this pattern suggests primary respiratory acidosis rather than metabolic alkalosis from chloride and hydrogen loss."
            },
            {
              "id": "B",
              "text": "Option A: pH 7.28, Pco2 30 mm Hg, HCO3- 14 mEq/L is inappropriate because this is a primary metabolic acidosis with respiratory compensation, which does not match the elevated serum bicarbonate after prolonged gastric fluid loss."
            },
            {
              "id": "C",
              "text": "Option C: pH 7.40, Pco2 40 mm Hg, HCO3- 24 mEq/L is inappropriate because a normal arterial blood gas would not fit the marked hypochloremia, hypokalemia, and elevated serum bicarbonate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "pH 7.33, Pco2 60 mm Hg, HCO3- 31 mEq/L is inappropriate because this pattern suggests primary respiratory acidosis rather than metabolic alkalosis from chloride and hydrogen loss."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "pH 7.40, Pco2 40 mm Hg, HCO3- 24 mEq/L is inappropriate because a normal arterial blood gas would not fit the marked hypochloremia, hypokalemia, and elevated serum bicarbonate."
            },
            {
              "id": "B",
              "text": "Option A: pH 7.28, Pco2 30 mm Hg, HCO3- 14 mEq/L is inappropriate because this is a primary metabolic acidosis with respiratory compensation, which does not match the elevated serum bicarbonate after prolonged gastric fluid loss."
            },
            {
              "id": "C",
              "text": "Option B: pH 7.33, Pco2 60 mm Hg, HCO3- 31 mEq/L is inappropriate because this pattern suggests primary respiratory acidosis rather than metabolic alkalosis from chloride and hydrogen loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "pH 7.40, Pco2 40 mm Hg, HCO3- 24 mEq/L is inappropriate because a normal arterial blood gas would not fit the marked hypochloremia, hypokalemia, and elevated serum bicarbonate."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "pH 7.44, Pco2 28 mm Hg, HCO3- 18 mEq/L is inappropriate because this is a primary respiratory alkalosis with renal compensation, not the expected effect of prolonged nasogastric suction."
            },
            {
              "id": "B",
              "text": "Option A: pH 7.28, Pco2 30 mm Hg, HCO3- 14 mEq/L is inappropriate because this is a primary metabolic acidosis with respiratory compensation, which does not match the elevated serum bicarbonate after prolonged gastric fluid loss."
            },
            {
              "id": "C",
              "text": "Option B: pH 7.33, Pco2 60 mm Hg, HCO3- 31 mEq/L is inappropriate because this pattern suggests primary respiratory acidosis rather than metabolic alkalosis from chloride and hydrogen loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "pH 7.44, Pco2 28 mm Hg, HCO3- 18 mEq/L is inappropriate because this is a primary respiratory alkalosis with renal compensation, not the expected effect of prolonged nasogastric suction."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "pH 7.47, Pco2 32 mm Hg, HCO3- 23 mEq/L is inappropriate because this shows alkalemia driven by low Pco2 rather than by elevated bicarbonate."
            },
            {
              "id": "B",
              "text": "Option A: pH 7.28, Pco2 30 mm Hg, HCO3- 14 mEq/L is inappropriate because this is a primary metabolic acidosis with respiratory compensation, which does not match the elevated serum bicarbonate after prolonged gastric fluid loss."
            },
            {
              "id": "C",
              "text": "Option B: pH 7.33, Pco2 60 mm Hg, HCO3- 31 mEq/L is inappropriate because this pattern suggests primary respiratory acidosis rather than metabolic alkalosis from chloride and hydrogen loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "pH 7.47, Pco2 32 mm Hg, HCO3- 23 mEq/L is inappropriate because this shows alkalemia driven by low Pco2 rather than by elevated bicarbonate."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "pH 7.56, Pco2 24 mm Hg, HCO3- 21 mEq/L is inappropriate because this pattern shows alkalemia with low Pco2 and low bicarbonate, which is inconsistent with the chemistry profile."
            },
            {
              "id": "B",
              "text": "Option A: pH 7.28, Pco2 30 mm Hg, HCO3- 14 mEq/L is inappropriate because this is a primary metabolic acidosis with respiratory compensation, which does not match the elevated serum bicarbonate after prolonged gastric fluid loss."
            },
            {
              "id": "C",
              "text": "Option B: pH 7.33, Pco2 60 mm Hg, HCO3- 31 mEq/L is inappropriate because this pattern suggests primary respiratory acidosis rather than metabolic alkalosis from chloride and hydrogen loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "pH 7.56, Pco2 24 mm Hg, HCO3- 21 mEq/L is inappropriate because this pattern shows alkalemia with low Pco2 and low bicarbonate, which is inconsistent with the chemistry profile."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i040-eplerenone-hyperkalemia-weakness",
      "expectedHashes": {
        "ranaze_step3_uat": "b02834bfad34befcca4e2d4a80480b62abe2b80c93adc209203bd19d7af03b72",
        "ranaze_step3_prd": "b02834bfad34befcca4e2d4a80480b62abe2b80c93adc209203bd19d7af03b72"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduced skeletal muscle perfusion from beta-1 receptor blockade is inappropriate because there is no beta-blocker on the medication list, and beta-1 blockade would not explain potassium of 6.4 mEq/L with peaked T waves."
            },
            {
              "id": "B",
              "text": "Option C: Immune-mediated demyelination of peripheral nerves is inappropriate because a demyelinating neuropathy would not explain the ECG pattern of peaked T waves and QRS widening with marked hyperkalemia."
            },
            {
              "id": "C",
              "text": "Option D: Excess calcium influx through T-type calcium channels is inappropriate because this does not account for the elevated potassium or the medication-triggered renal potassium retention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduced skeletal muscle perfusion from beta-1 receptor blockade is inappropriate because there is no beta-blocker on the medication list, and beta-1 blockade would not explain potassium of 6.4 mEq/L with peaked T waves."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immune-mediated demyelination of peripheral nerves is inappropriate because a demyelinating neuropathy would not explain the ECG pattern of peaked T waves and QRS widening with marked hyperkalemia."
            },
            {
              "id": "B",
              "text": "Option A: Reduced skeletal muscle perfusion from beta-1 receptor blockade is inappropriate because there is no beta-blocker on the medication list, and beta-1 blockade would not explain potassium of 6.4 mEq/L with peaked T waves."
            },
            {
              "id": "C",
              "text": "Option D: Excess calcium influx through T-type calcium channels is inappropriate because this does not account for the elevated potassium or the medication-triggered renal potassium retention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immune-mediated demyelination of peripheral nerves is inappropriate because a demyelinating neuropathy would not explain the ECG pattern of peaked T waves and QRS widening with marked hyperkalemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Excess calcium influx through T-type calcium channels is inappropriate because this does not account for the elevated potassium or the medication-triggered renal potassium retention."
            },
            {
              "id": "B",
              "text": "Option A: Reduced skeletal muscle perfusion from beta-1 receptor blockade is inappropriate because there is no beta-blocker on the medication list, and beta-1 blockade would not explain potassium of 6.4 mEq/L with peaked T waves."
            },
            {
              "id": "C",
              "text": "Option C: Immune-mediated demyelination of peripheral nerves is inappropriate because a demyelinating neuropathy would not explain the ECG pattern of peaked T waves and QRS widening with marked hyperkalemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Excess calcium influx through T-type calcium channels is inappropriate because this does not account for the elevated potassium or the medication-triggered renal potassium retention."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased breakdown of acetylcholine at the neuromuscular junction is inappropriate because a neuromuscular junction disorder would not explain the hyperkalemia and ECG changes."
            },
            {
              "id": "B",
              "text": "Option A: Reduced skeletal muscle perfusion from beta-1 receptor blockade is inappropriate because there is no beta-blocker on the medication list, and beta-1 blockade would not explain potassium of 6.4 mEq/L with peaked T waves."
            },
            {
              "id": "C",
              "text": "Option C: Immune-mediated demyelination of peripheral nerves is inappropriate because a demyelinating neuropathy would not explain the ECG pattern of peaked T waves and QRS widening with marked hyperkalemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased breakdown of acetylcholine at the neuromuscular junction is inappropriate because a neuromuscular junction disorder would not explain the hyperkalemia and ECG changes."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intracellular potassium shift caused by excess insulin activity is inappropriate because excess insulin drives potassium into cells and causes hypokalemia, the opposite of this patient\u0027s laboratory finding."
            },
            {
              "id": "B",
              "text": "Option A: Reduced skeletal muscle perfusion from beta-1 receptor blockade is inappropriate because there is no beta-blocker on the medication list, and beta-1 blockade would not explain potassium of 6.4 mEq/L with peaked T waves."
            },
            {
              "id": "C",
              "text": "Option C: Immune-mediated demyelination of peripheral nerves is inappropriate because a demyelinating neuropathy would not explain the ECG pattern of peaked T waves and QRS widening with marked hyperkalemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intracellular potassium shift caused by excess insulin activity is inappropriate because excess insulin drives potassium into cells and causes hypokalemia, the opposite of this patient\u0027s laboratory finding."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use-dependent sodium-channel blockade from a class Ic antiarrhythmic is inappropriate because there is no class Ic antiarrhythmic exposure, and the stem directly documents severe hyperkalemia."
            },
            {
              "id": "B",
              "text": "Option A: Reduced skeletal muscle perfusion from beta-1 receptor blockade is inappropriate because there is no beta-blocker on the medication list, and beta-1 blockade would not explain potassium of 6.4 mEq/L with peaked T waves."
            },
            {
              "id": "C",
              "text": "Option C: Immune-mediated demyelination of peripheral nerves is inappropriate because a demyelinating neuropathy would not explain the ECG pattern of peaked T waves and QRS widening with marked hyperkalemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use-dependent sodium-channel blockade from a class Ic antiarrhythmic is inappropriate because there is no class Ic antiarrhythmic exposure, and the stem directly documents severe hyperkalemia."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i042-stress-test-sensitivity-interpretation",
      "expectedHashes": {
        "ranaze_step3_uat": "6ff48fbc9960f0631610292b811c3a8d6406448ea76708365ecfc0a0fea8d49b",
        "ranaze_step3_prd": "6ff48fbc9960f0631610292b811c3a8d6406448ea76708365ecfc0a0fea8d49b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Among patients with a positive bedside test, 70% actually had septic arthritis is inappropriate because this describes positive predictive value, which depends on all positive tests, not all diseased patients."
            },
            {
              "id": "B",
              "text": "Option C: Among patients without septic arthritis, 70% had a negative bedside test is inappropriate because this refers to specificity, not sensitivity."
            },
            {
              "id": "C",
              "text": "Option D: Among all tested patients, 70% had septic arthritis is inappropriate because this is disease prevalence, not sensitivity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Among patients with a positive bedside test, 70% actually had septic arthritis is inappropriate because this describes positive predictive value, which depends on all positive tests, not all diseased patients."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Among patients without septic arthritis, 70% had a negative bedside test is inappropriate because this refers to specificity, not sensitivity."
            },
            {
              "id": "B",
              "text": "Option B: Among patients with a positive bedside test, 70% actually had septic arthritis is inappropriate because this describes positive predictive value, which depends on all positive tests, not all diseased patients."
            },
            {
              "id": "C",
              "text": "Option D: Among all tested patients, 70% had septic arthritis is inappropriate because this is disease prevalence, not sensitivity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Among patients without septic arthritis, 70% had a negative bedside test is inappropriate because this refers to specificity, not sensitivity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Among all tested patients, 70% had septic arthritis is inappropriate because this is disease prevalence, not sensitivity."
            },
            {
              "id": "B",
              "text": "Option B: Among patients with a positive bedside test, 70% actually had septic arthritis is inappropriate because this describes positive predictive value, which depends on all positive tests, not all diseased patients."
            },
            {
              "id": "C",
              "text": "Option C: Among patients without septic arthritis, 70% had a negative bedside test is inappropriate because this refers to specificity, not sensitivity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Among all tested patients, 70% had septic arthritis is inappropriate because this is disease prevalence, not sensitivity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Among patients with a negative bedside test, 70% were free of septic arthritis is inappropriate because this describes negative predictive value, not sensitivity."
            },
            {
              "id": "B",
              "text": "Option B: Among patients with a positive bedside test, 70% actually had septic arthritis is inappropriate because this describes positive predictive value, which depends on all positive tests, not all diseased patients."
            },
            {
              "id": "C",
              "text": "Option C: Among patients without septic arthritis, 70% had a negative bedside test is inappropriate because this refers to specificity, not sensitivity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Among patients with a negative bedside test, 70% were free of septic arthritis is inappropriate because this describes negative predictive value, not sensitivity."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The false-positive rate of the test was 70% is inappropriate because false-positive rate equals 1 minus specificity, not sensitivity."
            },
            {
              "id": "B",
              "text": "Option B: Among patients with a positive bedside test, 70% actually had septic arthritis is inappropriate because this describes positive predictive value, which depends on all positive tests, not all diseased patients."
            },
            {
              "id": "C",
              "text": "Option C: Among patients without septic arthritis, 70% had a negative bedside test is inappropriate because this refers to specificity, not sensitivity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The false-positive rate of the test was 70% is inappropriate because false-positive rate equals 1 minus specificity, not sensitivity."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The bedside test correctly classified 70% of all patients is inappropriate because overall accuracy is a different measure from sensitivity."
            },
            {
              "id": "B",
              "text": "Option B: Among patients with a positive bedside test, 70% actually had septic arthritis is inappropriate because this describes positive predictive value, which depends on all positive tests, not all diseased patients."
            },
            {
              "id": "C",
              "text": "Option C: Among patients without septic arthritis, 70% had a negative bedside test is inappropriate because this refers to specificity, not sensitivity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The bedside test correctly classified 70% of all patients is inappropriate because overall accuracy is a different measure from sensitivity."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i043-aniridia-flank-mass-wilms",
      "expectedHashes": {
        "ranaze_step3_uat": "006313e981a880859abc46376d18e88a7aed6ede40b18fb2efdf43f2846063cd",
        "ranaze_step3_prd": "006313e981a880859abc46376d18e88a7aed6ede40b18fb2efdf43f2846063cd"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Adrenocortical carcinoma may cause virilization or Cushing syndrome and does not fit the aniridia association or typical intrarenal mass."
            },
            {
              "id": "B",
              "text": "Option B: Hepatoblastoma arises from the liver, usually presents as a right upper quadrant hepatic mass, and is not associated with congenital aniridia."
            },
            {
              "id": "C",
              "text": "Option D: Neuroblastoma usually arises from the adrenal gland or sympathetic chain, often crosses the midline, and is less associated with congenital aniridia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Adrenocortical carcinoma may cause virilization or Cushing syndrome and does not fit the aniridia association or typical intrarenal mass."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hepatoblastoma arises from the liver, usually presents as a right upper quadrant hepatic mass, and is not associated with congenital aniridia."
            },
            {
              "id": "B",
              "text": "Option A: Adrenocortical carcinoma may cause virilization or Cushing syndrome and does not fit the aniridia association or typical intrarenal mass."
            },
            {
              "id": "C",
              "text": "Option D: Neuroblastoma usually arises from the adrenal gland or sympathetic chain, often crosses the midline, and is less associated with congenital aniridia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hepatoblastoma arises from the liver, usually presents as a right upper quadrant hepatic mass, and is not associated with congenital aniridia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neuroblastoma usually arises from the adrenal gland or sympathetic chain, often crosses the midline, and is less associated with congenital aniridia."
            },
            {
              "id": "B",
              "text": "Option A: Adrenocortical carcinoma may cause virilization or Cushing syndrome and does not fit the aniridia association or typical intrarenal mass."
            },
            {
              "id": "C",
              "text": "Option B: Hepatoblastoma arises from the liver, usually presents as a right upper quadrant hepatic mass, and is not associated with congenital aniridia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neuroblastoma usually arises from the adrenal gland or sympathetic chain, often crosses the midline, and is less associated with congenital aniridia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Rhabdomyosarcoma of the bladder is inappropriate because bladder rhabdomyosarcoma typically causes urinary obstruction or a grape-like mass, not a solid renal mass."
            },
            {
              "id": "B",
              "text": "Option A: Adrenocortical carcinoma may cause virilization or Cushing syndrome and does not fit the aniridia association or typical intrarenal mass."
            },
            {
              "id": "C",
              "text": "Option B: Hepatoblastoma arises from the liver, usually presents as a right upper quadrant hepatic mass, and is not associated with congenital aniridia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Rhabdomyosarcoma of the bladder is inappropriate because bladder rhabdomyosarcoma typically causes urinary obstruction or a grape-like mass, not a solid renal mass."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ovarian torsion presents with acute pain rather than a painless renal mass."
            },
            {
              "id": "B",
              "text": "Option A: Adrenocortical carcinoma may cause virilization or Cushing syndrome and does not fit the aniridia association or typical intrarenal mass."
            },
            {
              "id": "C",
              "text": "Option B: Hepatoblastoma arises from the liver, usually presents as a right upper quadrant hepatic mass, and is not associated with congenital aniridia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ovarian torsion presents with acute pain rather than a painless renal mass."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Renal cell carcinoma is uncommon in this age group."
            },
            {
              "id": "B",
              "text": "Option A: Adrenocortical carcinoma may cause virilization or Cushing syndrome and does not fit the aniridia association or typical intrarenal mass."
            },
            {
              "id": "C",
              "text": "Option B: Hepatoblastoma arises from the liver, usually presents as a right upper quadrant hepatic mass, and is not associated with congenital aniridia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Renal cell carcinoma is uncommon in this age group."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i044-periocular-hemangioma-vision-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "1ebc9ffda45c38feba1e6d06724f249d70c84913047cdd282465da0494a91f9b",
        "ranaze_step3_prd": "1ebc9ffda45c38feba1e6d06724f249d70c84913047cdd282465da0494a91f9b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A small superficial crust on the lesion is inappropriate because minor superficial crusting can occur in infantile hemangiomas, but it is not the strongest reason for urgent evaluation in this case."
            },
            {
              "id": "B",
              "text": "Option B: Age 6 weeks is inappropriate because this age is typical for the proliferative phase of infantile hemangiomas and is not the main urgency signal."
            },
            {
              "id": "C",
              "text": "Option C: A separate 2-mm papule on the buttock is inappropriate because a single additional tiny lesion does not by itself create the greatest immediate risk in this vignette."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A small superficial crust on the lesion is inappropriate because minor superficial crusting can occur in infantile hemangiomas, but it is not the strongest reason for urgent evaluation in this case."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Age 6 weeks is inappropriate because this age is typical for the proliferative phase of infantile hemangiomas and is not the main urgency signal."
            },
            {
              "id": "B",
              "text": "Option A: A small superficial crust on the lesion is inappropriate because minor superficial crusting can occur in infantile hemangiomas, but it is not the strongest reason for urgent evaluation in this case."
            },
            {
              "id": "C",
              "text": "Option C: A separate 2-mm papule on the buttock is inappropriate because a single additional tiny lesion does not by itself create the greatest immediate risk in this vignette."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Age 6 weeks is inappropriate because this age is typical for the proliferative phase of infantile hemangiomas and is not the main urgency signal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A separate 2-mm papule on the buttock is inappropriate because a single additional tiny lesion does not by itself create the greatest immediate risk in this vignette."
            },
            {
              "id": "B",
              "text": "Option A: A small superficial crust on the lesion is inappropriate because minor superficial crusting can occur in infantile hemangiomas, but it is not the strongest reason for urgent evaluation in this case."
            },
            {
              "id": "C",
              "text": "Option B: Age 6 weeks is inappropriate because this age is typical for the proliferative phase of infantile hemangiomas and is not the main urgency signal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A separate 2-mm papule on the buttock is inappropriate because a single additional tiny lesion does not by itself create the greatest immediate risk in this vignette."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thickening during the past 2 weeks is inappropriate because early growth is common for infantile hemangiomas and is less concerning than visual axis involvement."
            },
            {
              "id": "B",
              "text": "Option A: A small superficial crust on the lesion is inappropriate because minor superficial crusting can occur in infantile hemangiomas, but it is not the strongest reason for urgent evaluation in this case."
            },
            {
              "id": "C",
              "text": "Option B: Age 6 weeks is inappropriate because this age is typical for the proliferative phase of infantile hemangiomas and is not the main urgency signal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thickening during the past 2 weeks is inappropriate because early growth is common for infantile hemangiomas and is less concerning than visual axis involvement."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Presence since early infancy is inappropriate because appearance in early infancy is typical for infantile hemangioma and is not the key risk feature here."
            },
            {
              "id": "B",
              "text": "Option A: A small superficial crust on the lesion is inappropriate because minor superficial crusting can occur in infantile hemangiomas, but it is not the strongest reason for urgent evaluation in this case."
            },
            {
              "id": "C",
              "text": "Option B: Age 6 weeks is inappropriate because this age is typical for the proliferative phase of infantile hemangiomas and is not the main urgency signal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Presence since early infancy is inappropriate because appearance in early infancy is typical for infantile hemangioma and is not the key risk feature here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bright-red coloration is inappropriate because bright-red color is a common appearance of superficial infantile hemangioma and is not the major indication for urgent evaluation."
            },
            {
              "id": "B",
              "text": "Option A: A small superficial crust on the lesion is inappropriate because minor superficial crusting can occur in infantile hemangiomas, but it is not the strongest reason for urgent evaluation in this case."
            },
            {
              "id": "C",
              "text": "Option B: Age 6 weeks is inappropriate because this age is typical for the proliferative phase of infantile hemangiomas and is not the main urgency signal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bright-red coloration is inappropriate because bright-red color is a common appearance of superficial infantile hemangioma and is not the major indication for urgent evaluation."
        }
      }
    },
    {
      "externalId": "nbme6-s1-i048-disclose-ownership-conflict",
      "expectedHashes": {
        "ranaze_step3_uat": "6f7726d4178dc07ad47d2bc679810c4491507e32888dc8534e6b06cbaec66ed7",
        "ranaze_step3_prd": "6f7726d4178dc07ad47d2bc679810c4491507e32888dc8534e6b06cbaec66ed7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the hospital institutional review board to review the referral is inappropriate because institutional review boards oversee research ethics, not ordinary outpatient referral decisions in routine clinical care."
            },
            {
              "id": "B",
              "text": "Option C: Send the order to the owned imaging center without discussing the ownership interest because it is nearby is inappropriate because convenience does not justify sending the patient to a physician-owned facility without disclosure."
            },
            {
              "id": "C",
              "text": "Option D: Recommend a different imaging center but do not mention the ownership interest is inappropriate because sending the patient elsewhere still fails to address the undisclosed financial conflict."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the hospital institutional review board to review the referral is inappropriate because institutional review boards oversee research ethics, not ordinary outpatient referral decisions in routine clinical care."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Send the order to the owned imaging center without discussing the ownership interest because it is nearby is inappropriate because convenience does not justify sending the patient to a physician-owned facility without disclosure."
            },
            {
              "id": "B",
              "text": "Option A: Ask the hospital institutional review board to review the referral is inappropriate because institutional review boards oversee research ethics, not ordinary outpatient referral decisions in routine clinical care."
            },
            {
              "id": "C",
              "text": "Option D: Recommend a different imaging center but do not mention the ownership interest is inappropriate because sending the patient elsewhere still fails to address the undisclosed financial conflict."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Send the order to the owned imaging center without discussing the ownership interest because it is nearby is inappropriate because convenience does not justify sending the patient to a physician-owned facility without disclosure."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend a different imaging center but do not mention the ownership interest is inappropriate because sending the patient elsewhere still fails to address the undisclosed financial conflict."
            },
            {
              "id": "B",
              "text": "Option A: Ask the hospital institutional review board to review the referral is inappropriate because institutional review boards oversee research ethics, not ordinary outpatient referral decisions in routine clinical care."
            },
            {
              "id": "C",
              "text": "Option C: Send the order to the owned imaging center without discussing the ownership interest because it is nearby is inappropriate because convenience does not justify sending the patient to a physician-owned facility without disclosure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend a different imaging center but do not mention the ownership interest is inappropriate because sending the patient elsewhere still fails to address the undisclosed financial conflict."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Advise the patient to get a second opinion before deciding where to obtain the imaging is inappropriate because a second opinion is unnecessary when the indicated test is already clear; the issue is disclosure, not diagnostic uncertainty."
            },
            {
              "id": "B",
              "text": "Option A: Ask the hospital institutional review board to review the referral is inappropriate because institutional review boards oversee research ethics, not ordinary outpatient referral decisions in routine clinical care."
            },
            {
              "id": "C",
              "text": "Option C: Send the order to the owned imaging center without discussing the ownership interest because it is nearby is inappropriate because convenience does not justify sending the patient to a physician-owned facility without disclosure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Advise the patient to get a second opinion before deciding where to obtain the imaging is inappropriate because a second opinion is unnecessary when the indicated test is already clear; the issue is disclosure, not diagnostic uncertainty."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Let the patient\u0027s insurer choose the facility without discussing the conflict with the patient is inappropriate because having the insurer choose the site does not remove the physician\u0027s duty to disclose the ownership interest to the patient."
            },
            {
              "id": "B",
              "text": "Option A: Ask the hospital institutional review board to review the referral is inappropriate because institutional review boards oversee research ethics, not ordinary outpatient referral decisions in routine clinical care."
            },
            {
              "id": "C",
              "text": "Option C: Send the order to the owned imaging center without discussing the ownership interest because it is nearby is inappropriate because convenience does not justify sending the patient to a physician-owned facility without disclosure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Let the patient\u0027s insurer choose the facility without discussing the conflict with the patient is inappropriate because having the insurer choose the site does not remove the physician\u0027s duty to disclose the ownership interest to the patient."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay the imaging order until the physician no longer owns part of the center is inappropriate because necessary evaluation for gross hematuria should not be delayed simply because the physician has a financial conflict."
            },
            {
              "id": "B",
              "text": "Option A: Ask the hospital institutional review board to review the referral is inappropriate because institutional review boards oversee research ethics, not ordinary outpatient referral decisions in routine clinical care."
            },
            {
              "id": "C",
              "text": "Option C: Send the order to the owned imaging center without discussing the ownership interest because it is nearby is inappropriate because convenience does not justify sending the patient to a physician-owned facility without disclosure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay the imaging order until the physician no longer owns part of the center is inappropriate because necessary evaluation for gross hematuria should not be delayed simply because the physician has a financial conflict."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i002-child-encopresis-reassurance",
      "expectedHashes": {
        "ranaze_step3_uat": "cbb2b17c398351674670e693a0917e30fb15eddd2ae68d1f5a5c11e9d1fb4a8e",
        "ranaze_step3_prd": "cbb2b17c398351674670e693a0917e30fb15eddd2ae68d1f5a5c11e9d1fb4a8e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022This pattern raises major concern for sexual abuse, and that is the main issue we need to address first.\u0022 is inappropriate because abuse can contribute to regression or behavioral change, but this stem is dominated by classic stool withholding and overflow constipation findings rather than trauma-specific red flags."
            },
            {
              "id": "B",
              "text": "Option B: \u0022This presentation is most worrisome for inflammatory bowel disease and she should have colonoscopy before treatment.\u0022 is inappropriate because inflammatory bowel disease usually causes weight loss, blood, chronic diarrhea, growth failure, or systemic inflammation, not infrequent large painful stools with overflow soiling."
            },
            {
              "id": "C",
              "text": "Option D: \u0022This degree of soiling usually means a spinal cord disorder, so bowel treatment is unlikely to help.\u0022 is inappropriate because a spinal cord disorder would be suggested by gait abnormality, lower-extremity weakness, abnormal reflexes, urinary symptoms, or abnormal perianal sensation, none of which are present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022This pattern raises major concern for sexual abuse, and that is the main issue we need to address first.\u0022 is inappropriate because abuse can contribute to regression or behavioral change, but this stem is dominated by classic stool withholding and overflow constipation findings rather than trauma-specific red flags."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022This presentation is most worrisome for inflammatory bowel disease and she should have colonoscopy before treatment.\u0022 is inappropriate because inflammatory bowel disease usually causes weight loss, blood, chronic diarrhea, growth failure, or systemic inflammation, not infrequent large painful stools with overflow soiling."
            },
            {
              "id": "B",
              "text": "Option A: \u0022This pattern raises major concern for sexual abuse, and that is the main issue we need to address first.\u0022 is inappropriate because abuse can contribute to regression or behavioral change, but this stem is dominated by classic stool withholding and overflow constipation findings rather than trauma-specific red flags."
            },
            {
              "id": "C",
              "text": "Option D: \u0022This degree of soiling usually means a spinal cord disorder, so bowel treatment is unlikely to help.\u0022 is inappropriate because a spinal cord disorder would be suggested by gait abnormality, lower-extremity weakness, abnormal reflexes, urinary symptoms, or abnormal perianal sensation, none of which are present here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022This presentation is most worrisome for inflammatory bowel disease and she should have colonoscopy before treatment.\u0022 is inappropriate because inflammatory bowel disease usually causes weight loss, blood, chronic diarrhea, growth failure, or systemic inflammation, not infrequent large painful stools with overflow soiling."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022This degree of soiling usually means a spinal cord disorder, so bowel treatment is unlikely to help.\u0022 is inappropriate because a spinal cord disorder would be suggested by gait abnormality, lower-extremity weakness, abnormal reflexes, urinary symptoms, or abnormal perianal sensation, none of which are present here."
            },
            {
              "id": "B",
              "text": "Option A: \u0022This pattern raises major concern for sexual abuse, and that is the main issue we need to address first.\u0022 is inappropriate because abuse can contribute to regression or behavioral change, but this stem is dominated by classic stool withholding and overflow constipation findings rather than trauma-specific red flags."
            },
            {
              "id": "C",
              "text": "Option B: \u0022This presentation is most worrisome for inflammatory bowel disease and she should have colonoscopy before treatment.\u0022 is inappropriate because inflammatory bowel disease usually causes weight loss, blood, chronic diarrhea, growth failure, or systemic inflammation, not infrequent large painful stools with overflow soiling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022This degree of soiling usually means a spinal cord disorder, so bowel treatment is unlikely to help.\u0022 is inappropriate because a spinal cord disorder would be suggested by gait abnormality, lower-extremity weakness, abnormal reflexes, urinary symptoms, or abnormal perianal sensation, none of which are present here."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022This is primarily oppositional behavior, so strict consequences are the key treatment.\u0022 is inappropriate because punitive or discipline-focused framing is inappropriate because the soiling is usually involuntary overflow from retained stool rather than deliberate misbehavior."
            },
            {
              "id": "B",
              "text": "Option A: \u0022This pattern raises major concern for sexual abuse, and that is the main issue we need to address first.\u0022 is inappropriate because abuse can contribute to regression or behavioral change, but this stem is dominated by classic stool withholding and overflow constipation findings rather than trauma-specific red flags."
            },
            {
              "id": "C",
              "text": "Option B: \u0022This presentation is most worrisome for inflammatory bowel disease and she should have colonoscopy before treatment.\u0022 is inappropriate because inflammatory bowel disease usually causes weight loss, blood, chronic diarrhea, growth failure, or systemic inflammation, not infrequent large painful stools with overflow soiling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022This is primarily oppositional behavior, so strict consequences are the key treatment.\u0022 is inappropriate because punitive or discipline-focused framing is inappropriate because the soiling is usually involuntary overflow from retained stool rather than deliberate misbehavior."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022This usually reflects a congenital bowel disorder that will need surgery for correction.\u0022 is inappropriate because hirschsprung disease typically presents much earlier and is associated with neonatal or longstanding severe symptoms rather than a later stool-withholding pattern in an otherwise neurologically normal child."
            },
            {
              "id": "B",
              "text": "Option A: \u0022This pattern raises major concern for sexual abuse, and that is the main issue we need to address first.\u0022 is inappropriate because abuse can contribute to regression or behavioral change, but this stem is dominated by classic stool withholding and overflow constipation findings rather than trauma-specific red flags."
            },
            {
              "id": "C",
              "text": "Option B: \u0022This presentation is most worrisome for inflammatory bowel disease and she should have colonoscopy before treatment.\u0022 is inappropriate because inflammatory bowel disease usually causes weight loss, blood, chronic diarrhea, growth failure, or systemic inflammation, not infrequent large painful stools with overflow soiling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022This usually reflects a congenital bowel disorder that will need surgery for correction.\u0022 is inappropriate because hirschsprung disease typically presents much earlier and is associated with neonatal or longstanding severe symptoms rather than a later stool-withholding pattern in an otherwise neurologically normal child."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022This is most likely a food allergy, so elimination diets should be the main next step.\u0022 is inappropriate because food allergy is not the best explanation for this classic constipation pattern and is not first-line management in a child without compatible allergic or enterocolitic features."
            },
            {
              "id": "B",
              "text": "Option A: \u0022This pattern raises major concern for sexual abuse, and that is the main issue we need to address first.\u0022 is inappropriate because abuse can contribute to regression or behavioral change, but this stem is dominated by classic stool withholding and overflow constipation findings rather than trauma-specific red flags."
            },
            {
              "id": "C",
              "text": "Option B: \u0022This presentation is most worrisome for inflammatory bowel disease and she should have colonoscopy before treatment.\u0022 is inappropriate because inflammatory bowel disease usually causes weight loss, blood, chronic diarrhea, growth failure, or systemic inflammation, not infrequent large painful stools with overflow soiling."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022This is most likely a food allergy, so elimination diets should be the main next step.\u0022 is inappropriate because food allergy is not the best explanation for this classic constipation pattern and is not first-line management in a child without compatible allergic or enterocolitic features."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i003-child-constipation-no-further-testing",
      "expectedHashes": {
        "ranaze_step3_uat": "8a538f018d435183e339d287bfda49c3b9afac9eaacc69b3dfd15dbb79b4e1e6",
        "ranaze_step3_prd": "8a538f018d435183e339d287bfda49c3b9afac9eaacc69b3dfd15dbb79b4e1e6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anorectal manometry is reserved for suspected Hirschsprung disease or refractory defecatory disorders, not straightforward functional constipation without red flags."
            },
            {
              "id": "B",
              "text": "Option B: Celiac serologic testing is inappropriate because celiac testing can be considered when constipation occurs with poor growth or other suggestive features, which are absent here."
            },
            {
              "id": "C",
              "text": "Option C: Contrast enema is not indicated for routine evaluation of typical functional constipation after a reassuring history and examination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anorectal manometry is reserved for suspected Hirschsprung disease or refractory defecatory disorders, not straightforward functional constipation without red flags."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Celiac serologic testing is inappropriate because celiac testing can be considered when constipation occurs with poor growth or other suggestive features, which are absent here."
            },
            {
              "id": "B",
              "text": "Option A: Anorectal manometry is reserved for suspected Hirschsprung disease or refractory defecatory disorders, not straightforward functional constipation without red flags."
            },
            {
              "id": "C",
              "text": "Option C: Contrast enema is not indicated for routine evaluation of typical functional constipation after a reassuring history and examination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Celiac serologic testing is inappropriate because celiac testing can be considered when constipation occurs with poor growth or other suggestive features, which are absent here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contrast enema is not indicated for routine evaluation of typical functional constipation after a reassuring history and examination."
            },
            {
              "id": "B",
              "text": "Option A: Anorectal manometry is reserved for suspected Hirschsprung disease or refractory defecatory disorders, not straightforward functional constipation without red flags."
            },
            {
              "id": "C",
              "text": "Option B: Celiac serologic testing is inappropriate because celiac testing can be considered when constipation occurs with poor growth or other suggestive features, which are absent here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contrast enema is not indicated for routine evaluation of typical functional constipation after a reassuring history and examination."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbosacral spine MRI is inappropriate because spine MRI is used when neurologic or lumbosacral findings suggest tethered cord or other neurogenic causes; none are present."
            },
            {
              "id": "B",
              "text": "Option A: Anorectal manometry is reserved for suspected Hirschsprung disease or refractory defecatory disorders, not straightforward functional constipation without red flags."
            },
            {
              "id": "C",
              "text": "Option B: Celiac serologic testing is inappropriate because celiac testing can be considered when constipation occurs with poor growth or other suggestive features, which are absent here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbosacral spine MRI is inappropriate because spine MRI is used when neurologic or lumbosacral findings suggest tethered cord or other neurogenic causes; none are present."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum thyroid-stimulating hormone measurement is inappropriate because tSH testing may be appropriate when hypothyroidism is suspected clinically, but there are no supporting features in this stem."
            },
            {
              "id": "B",
              "text": "Option A: Anorectal manometry is reserved for suspected Hirschsprung disease or refractory defecatory disorders, not straightforward functional constipation without red flags."
            },
            {
              "id": "C",
              "text": "Option B: Celiac serologic testing is inappropriate because celiac testing can be considered when constipation occurs with poor growth or other suggestive features, which are absent here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum thyroid-stimulating hormone measurement is inappropriate because tSH testing may be appropriate when hypothyroidism is suspected clinically, but there are no supporting features in this stem."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unprepped flexible sigmoidoscopy is inappropriate because flexible sigmoidoscopy is not part of the routine workup for a child with classic retentive constipation and no bleeding or inflammatory features."
            },
            {
              "id": "B",
              "text": "Option A: Anorectal manometry is reserved for suspected Hirschsprung disease or refractory defecatory disorders, not straightforward functional constipation without red flags."
            },
            {
              "id": "C",
              "text": "Option B: Celiac serologic testing is inappropriate because celiac testing can be considered when constipation occurs with poor growth or other suggestive features, which are absent here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unprepped flexible sigmoidoscopy is inappropriate because flexible sigmoidoscopy is not part of the routine workup for a child with classic retentive constipation and no bleeding or inflammatory features."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i007-candidal-vaginitis-koh",
      "expectedHashes": {
        "ranaze_step3_uat": "e4911ac8a2eecd35b082fd333542d9ce472961e9a0747619a15f551786f1e54b",
        "ranaze_step3_prd": "e4911ac8a2eecd35b082fd333542d9ce472961e9a0747619a15f551786f1e54b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bacterial culture of vaginal secretions is inappropriate because routine bacterial culture is not the best confirmatory test for a presentation most consistent with vulvovaginal candidiasis."
            },
            {
              "id": "B",
              "text": "Option B: Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhoeae is inappropriate because nAAT for chlamydia and gonorrhea is useful for cervicitis screening but would not best confirm this cause of vulvovaginal itching with clumped white discharge."
            },
            {
              "id": "C",
              "text": "Option C: Saline wet mount microscopy for motile organisms is inappropriate because saline wet mount is more useful for identifying motile trichomonads or clue cells than for improving visualization of yeast forms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bacterial culture of vaginal secretions is inappropriate because routine bacterial culture is not the best confirmatory test for a presentation most consistent with vulvovaginal candidiasis."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhoeae is inappropriate because nAAT for chlamydia and gonorrhea is useful for cervicitis screening but would not best confirm this cause of vulvovaginal itching with clumped white discharge."
            },
            {
              "id": "B",
              "text": "Option A: Bacterial culture of vaginal secretions is inappropriate because routine bacterial culture is not the best confirmatory test for a presentation most consistent with vulvovaginal candidiasis."
            },
            {
              "id": "C",
              "text": "Option C: Saline wet mount microscopy for motile organisms is inappropriate because saline wet mount is more useful for identifying motile trichomonads or clue cells than for improving visualization of yeast forms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhoeae is inappropriate because nAAT for chlamydia and gonorrhea is useful for cervicitis screening but would not best confirm this cause of vulvovaginal itching with clumped white discharge."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Saline wet mount microscopy for motile organisms is inappropriate because saline wet mount is more useful for identifying motile trichomonads or clue cells than for improving visualization of yeast forms."
            },
            {
              "id": "B",
              "text": "Option A: Bacterial culture of vaginal secretions is inappropriate because routine bacterial culture is not the best confirmatory test for a presentation most consistent with vulvovaginal candidiasis."
            },
            {
              "id": "C",
              "text": "Option B: Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhoeae is inappropriate because nAAT for chlamydia and gonorrhea is useful for cervicitis screening but would not best confirm this cause of vulvovaginal itching with clumped white discharge."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Saline wet mount microscopy for motile organisms is inappropriate because saline wet mount is more useful for identifying motile trichomonads or clue cells than for improving visualization of yeast forms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Papanicolaou cytology is a cervical cancer screening test and is not used to confirm this diagnosis."
            },
            {
              "id": "B",
              "text": "Option A: Bacterial culture of vaginal secretions is inappropriate because routine bacterial culture is not the best confirmatory test for a presentation most consistent with vulvovaginal candidiasis."
            },
            {
              "id": "C",
              "text": "Option B: Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhoeae is inappropriate because nAAT for chlamydia and gonorrhea is useful for cervicitis screening but would not best confirm this cause of vulvovaginal itching with clumped white discharge."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Papanicolaou cytology is a cervical cancer screening test and is not used to confirm this diagnosis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Polymerase chain reaction testing for herpes simplex virus is inappropriate because hSV PCR is used when vesicular or ulcerative lesions suggest herpes infection, which is not the picture here."
            },
            {
              "id": "B",
              "text": "Option A: Bacterial culture of vaginal secretions is inappropriate because routine bacterial culture is not the best confirmatory test for a presentation most consistent with vulvovaginal candidiasis."
            },
            {
              "id": "C",
              "text": "Option B: Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhoeae is inappropriate because nAAT for chlamydia and gonorrhea is useful for cervicitis screening but would not best confirm this cause of vulvovaginal itching with clumped white discharge."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Polymerase chain reaction testing for herpes simplex virus is inappropriate because hSV PCR is used when vesicular or ulcerative lesions suggest herpes infection, which is not the picture here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat vaginal pH measurement is inappropriate because the vaginal pH is already given as normal, and repeating it would not confirm the suspected yeast infection."
            },
            {
              "id": "B",
              "text": "Option A: Bacterial culture of vaginal secretions is inappropriate because routine bacterial culture is not the best confirmatory test for a presentation most consistent with vulvovaginal candidiasis."
            },
            {
              "id": "C",
              "text": "Option B: Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhoeae is inappropriate because nAAT for chlamydia and gonorrhea is useful for cervicitis screening but would not best confirm this cause of vulvovaginal itching with clumped white discharge."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat vaginal pH measurement is inappropriate because the vaginal pH is already given as normal, and repeating it would not confirm the suspected yeast infection."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i009-umbilical-cord-prolapse-emergency",
      "expectedHashes": {
        "ranaze_step3_uat": "26043f5439c80b2e6629a9c74f44bab7e91ef77dc99abd4da76f48579044d767",
        "ranaze_step3_prd": "26043f5439c80b2e6629a9c74f44bab7e91ef77dc99abd4da76f48579044d767"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer terbutaline and observe for spontaneous resolution of the cord prolapse is inappropriate because tocolysis does not definitively treat cord prolapse and should not delay urgent delivery."
            },
            {
              "id": "B",
              "text": "Option C: Apply traction to the presenting foot to expedite vaginal delivery is inappropriate because traction on a footling presenting part risks trauma and does not address the danger of cord compression."
            },
            {
              "id": "C",
              "text": "Option D: Attempt to replace the umbilical cord back into the uterus and continue labor is inappropriate because manual replacement of the cord is not reliable definitive management and should not delay cesarean delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer terbutaline and observe for spontaneous resolution of the cord prolapse is inappropriate because tocolysis does not definitively treat cord prolapse and should not delay urgent delivery."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply traction to the presenting foot to expedite vaginal delivery is inappropriate because traction on a footling presenting part risks trauma and does not address the danger of cord compression."
            },
            {
              "id": "B",
              "text": "Option A: Administer terbutaline and observe for spontaneous resolution of the cord prolapse is inappropriate because tocolysis does not definitively treat cord prolapse and should not delay urgent delivery."
            },
            {
              "id": "C",
              "text": "Option D: Attempt to replace the umbilical cord back into the uterus and continue labor is inappropriate because manual replacement of the cord is not reliable definitive management and should not delay cesarean delivery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply traction to the presenting foot to expedite vaginal delivery is inappropriate because traction on a footling presenting part risks trauma and does not address the danger of cord compression."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Attempt to replace the umbilical cord back into the uterus and continue labor is inappropriate because manual replacement of the cord is not reliable definitive management and should not delay cesarean delivery."
            },
            {
              "id": "B",
              "text": "Option A: Administer terbutaline and observe for spontaneous resolution of the cord prolapse is inappropriate because tocolysis does not definitively treat cord prolapse and should not delay urgent delivery."
            },
            {
              "id": "C",
              "text": "Option C: Apply traction to the presenting foot to expedite vaginal delivery is inappropriate because traction on a footling presenting part risks trauma and does not address the danger of cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Attempt to replace the umbilical cord back into the uterus and continue labor is inappropriate because manual replacement of the cord is not reliable definitive management and should not delay cesarean delivery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin oxytocin infusion to shorten the duration of labor is inappropriate because oxytocin would increase contractions and potentially worsen cord compression."
            },
            {
              "id": "B",
              "text": "Option A: Administer terbutaline and observe for spontaneous resolution of the cord prolapse is inappropriate because tocolysis does not definitively treat cord prolapse and should not delay urgent delivery."
            },
            {
              "id": "C",
              "text": "Option C: Apply traction to the presenting foot to expedite vaginal delivery is inappropriate because traction on a footling presenting part risks trauma and does not address the danger of cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin oxytocin infusion to shorten the duration of labor is inappropriate because oxytocin would increase contractions and potentially worsen cord compression."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place the patient upright and recheck the cervix in 1 hour is inappropriate because observation is unsafe in the setting of a pulsating prolapsed cord."
            },
            {
              "id": "B",
              "text": "Option A: Administer terbutaline and observe for spontaneous resolution of the cord prolapse is inappropriate because tocolysis does not definitively treat cord prolapse and should not delay urgent delivery."
            },
            {
              "id": "C",
              "text": "Option C: Apply traction to the presenting foot to expedite vaginal delivery is inappropriate because traction on a footling presenting part risks trauma and does not address the danger of cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place the patient upright and recheck the cervix in 1 hour is inappropriate because observation is unsafe in the setting of a pulsating prolapsed cord."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use forceps to deliver the fetus through the partially dilated cervix is inappropriate because operative vaginal delivery is inappropriate with incomplete dilation and a footling preterm presentation."
            },
            {
              "id": "B",
              "text": "Option A: Administer terbutaline and observe for spontaneous resolution of the cord prolapse is inappropriate because tocolysis does not definitively treat cord prolapse and should not delay urgent delivery."
            },
            {
              "id": "C",
              "text": "Option C: Apply traction to the presenting foot to expedite vaginal delivery is inappropriate because traction on a footling presenting part risks trauma and does not address the danger of cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use forceps to deliver the fetus through the partially dilated cervix is inappropriate because operative vaginal delivery is inappropriate with incomplete dilation and a footling preterm presentation."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i010-fatigable-bulbar-weakness-testing",
      "expectedHashes": {
        "ranaze_step3_uat": "0c33278e56bddbe00c9c1237b4a923b56b4f1db4f7bf0bc69a8632c96513b52f",
        "ranaze_step3_prd": "0c33278e56bddbe00c9c1237b4a923b56b4f1db4f7bf0bc69a8632c96513b52f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Brain MRI with diffusion-weighted imaging is inappropriate because stroke would not cause fluctuating fatigability that worsens with sustained use and improves with rest over weeks."
            },
            {
              "id": "B",
              "text": "Option B: Laryngoscopy during phonation is inappropriate because laryngoscopy may visualize vocal cord motion but does not confirm the underlying neuromuscular junction disorder."
            },
            {
              "id": "C",
              "text": "Option C: Modified barium swallow study is inappropriate because a swallow study can assess aspiration risk but is not the confirmatory test for myasthenia gravis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Brain MRI with diffusion-weighted imaging is inappropriate because stroke would not cause fluctuating fatigability that worsens with sustained use and improves with rest over weeks."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Laryngoscopy during phonation is inappropriate because laryngoscopy may visualize vocal cord motion but does not confirm the underlying neuromuscular junction disorder."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI with diffusion-weighted imaging is inappropriate because stroke would not cause fluctuating fatigability that worsens with sustained use and improves with rest over weeks."
            },
            {
              "id": "C",
              "text": "Option C: Modified barium swallow study is inappropriate because a swallow study can assess aspiration risk but is not the confirmatory test for myasthenia gravis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Laryngoscopy during phonation is inappropriate because laryngoscopy may visualize vocal cord motion but does not confirm the underlying neuromuscular junction disorder."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Modified barium swallow study is inappropriate because a swallow study can assess aspiration risk but is not the confirmatory test for myasthenia gravis."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI with diffusion-weighted imaging is inappropriate because stroke would not cause fluctuating fatigability that worsens with sustained use and improves with rest over weeks."
            },
            {
              "id": "C",
              "text": "Option B: Laryngoscopy during phonation is inappropriate because laryngoscopy may visualize vocal cord motion but does not confirm the underlying neuromuscular junction disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Modified barium swallow study is inappropriate because a swallow study can assess aspiration risk but is not the confirmatory test for myasthenia gravis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum creatine kinase measurement is inappropriate because creatine kinase is often normal in myasthenia gravis and is more useful when a primary myopathy is suspected."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI with diffusion-weighted imaging is inappropriate because stroke would not cause fluctuating fatigability that worsens with sustained use and improves with rest over weeks."
            },
            {
              "id": "C",
              "text": "Option B: Laryngoscopy during phonation is inappropriate because laryngoscopy may visualize vocal cord motion but does not confirm the underlying neuromuscular junction disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum creatine kinase measurement is inappropriate because creatine kinase is often normal in myasthenia gravis and is more useful when a primary myopathy is suspected."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum thyroid-stimulating hormone measurement is inappropriate because thyroid disease can coexist with myasthenia gravis but does not explain the fatigable bulbar and ocular pattern here."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI with diffusion-weighted imaging is inappropriate because stroke would not cause fluctuating fatigability that worsens with sustained use and improves with rest over weeks."
            },
            {
              "id": "C",
              "text": "Option B: Laryngoscopy during phonation is inappropriate because laryngoscopy may visualize vocal cord motion but does not confirm the underlying neuromuscular junction disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum thyroid-stimulating hormone measurement is inappropriate because thyroid disease can coexist with myasthenia gravis but does not explain the fatigable bulbar and ocular pattern here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum vitamin B12 concentration is inappropriate because borderline hematologic values do not explain fluctuating ptosis and dysarthria, and vitamin B12 deficiency would not present this way."
            },
            {
              "id": "B",
              "text": "Option A: Brain MRI with diffusion-weighted imaging is inappropriate because stroke would not cause fluctuating fatigability that worsens with sustained use and improves with rest over weeks."
            },
            {
              "id": "C",
              "text": "Option B: Laryngoscopy during phonation is inappropriate because laryngoscopy may visualize vocal cord motion but does not confirm the underlying neuromuscular junction disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum vitamin B12 concentration is inappropriate because borderline hematologic values do not explain fluctuating ptosis and dysarthria, and vitamin B12 deficiency would not present this way."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i014-injury-pattern-safety-assessment",
      "expectedHashes": {
        "ranaze_step3_uat": "6ee9fa6e3c4e26a1be82f3822099dd89dc7c584c11e4f940bd9826d20b523d73",
        "ranaze_step3_prd": "6ee9fa6e3c4e26a1be82f3822099dd89dc7c584c11e4f940bd9826d20b523d73"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask her partner to explain again how the injuries occurred is inappropriate because questioning the partner again can increase risk and does not replace a private assessment with the patient."
            },
            {
              "id": "B",
              "text": "Option B: Call police from the clinic without discussing it with her is inappropriate because automatic police involvement is not the best first step for a competent adult patient who can participate in safety planning and decision-making."
            },
            {
              "id": "C",
              "text": "Option C: Arrange immediate psychiatric admission is inappropriate because she denies suicidal thoughts and has no indication for involuntary psychiatric admission based on the information given."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask her partner to explain again how the injuries occurred is inappropriate because questioning the partner again can increase risk and does not replace a private assessment with the patient."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Call police from the clinic without discussing it with her is inappropriate because automatic police involvement is not the best first step for a competent adult patient who can participate in safety planning and decision-making."
            },
            {
              "id": "B",
              "text": "Option A: Ask her partner to explain again how the injuries occurred is inappropriate because questioning the partner again can increase risk and does not replace a private assessment with the patient."
            },
            {
              "id": "C",
              "text": "Option C: Arrange immediate psychiatric admission is inappropriate because she denies suicidal thoughts and has no indication for involuntary psychiatric admission based on the information given."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Call police from the clinic without discussing it with her is inappropriate because automatic police involvement is not the best first step for a competent adult patient who can participate in safety planning and decision-making."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange immediate psychiatric admission is inappropriate because she denies suicidal thoughts and has no indication for involuntary psychiatric admission based on the information given."
            },
            {
              "id": "B",
              "text": "Option A: Ask her partner to explain again how the injuries occurred is inappropriate because questioning the partner again can increase risk and does not replace a private assessment with the patient."
            },
            {
              "id": "C",
              "text": "Option B: Call police from the clinic without discussing it with her is inappropriate because automatic police involvement is not the best first step for a competent adult patient who can participate in safety planning and decision-making."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange immediate psychiatric admission is inappropriate because she denies suicidal thoughts and has no indication for involuntary psychiatric admission based on the information given."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contact her sister despite her request not to involve family is inappropriate because contacting family against her stated wishes undermines autonomy and may increase danger."
            },
            {
              "id": "B",
              "text": "Option A: Ask her partner to explain again how the injuries occurred is inappropriate because questioning the partner again can increase risk and does not replace a private assessment with the patient."
            },
            {
              "id": "C",
              "text": "Option B: Call police from the clinic without discussing it with her is inappropriate because automatic police involvement is not the best first step for a competent adult patient who can participate in safety planning and decision-making."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contact her sister despite her request not to involve family is inappropriate because contacting family against her stated wishes undermines autonomy and may increase danger."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discharge her with routine fracture follow-up only is inappropriate because multiple injuries in different stages of healing require further assessment for safety before discharge."
            },
            {
              "id": "B",
              "text": "Option A: Ask her partner to explain again how the injuries occurred is inappropriate because questioning the partner again can increase risk and does not replace a private assessment with the patient."
            },
            {
              "id": "C",
              "text": "Option B: Call police from the clinic without discussing it with her is inappropriate because automatic police involvement is not the best first step for a competent adult patient who can participate in safety planning and decision-making."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discharge her with routine fracture follow-up only is inappropriate because multiple injuries in different stages of healing require further assessment for safety before discharge."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange transport to a shelter without first asking what she wants is inappropriate because even well-intentioned resource use should be patient-centered; arranging shelter without asking her preference is not the best next step."
            },
            {
              "id": "B",
              "text": "Option A: Ask her partner to explain again how the injuries occurred is inappropriate because questioning the partner again can increase risk and does not replace a private assessment with the patient."
            },
            {
              "id": "C",
              "text": "Option B: Call police from the clinic without discussing it with her is inappropriate because automatic police involvement is not the best first step for a competent adult patient who can participate in safety planning and decision-making."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange transport to a shelter without first asking what she wants is inappropriate because even well-intentioned resource use should be patient-centered; arranging shelter without asking her preference is not the best next step."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i016-septic-shock-vasopressor",
      "expectedHashes": {
        "ranaze_step3_uat": "31979bed593f4b39b7a9112cbb2486ecb3ec749f6c2f57b011d64cdd673dc03c",
        "ranaze_step3_prd": "31979bed593f4b39b7a9112cbb2486ecb3ec749f6c2f57b011d64cdd673dc03c"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Albumin infusion is inappropriate because albumin can be considered in selected patients who need large volumes of crystalloid, but it is not the preferred next pharmacologic step when shock persists after initial fluid resuscitation."
            },
            {
              "id": "B",
              "text": "Option B: Dobutamine infusion is inappropriate because dobutamine is primarily an inotrope for patients with myocardial dysfunction or ongoing hypoperfusion despite adequate blood pressure; it is not first-line for isolated vasodilatory septic shock."
            },
            {
              "id": "C",
              "text": "Option C: Hydrocortisone can be added in refractory septic shock despite fluids and vasopressors, but vasopressor therapy should be started first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Albumin infusion is inappropriate because albumin can be considered in selected patients who need large volumes of crystalloid, but it is not the preferred next pharmacologic step when shock persists after initial fluid resuscitation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dobutamine infusion is inappropriate because dobutamine is primarily an inotrope for patients with myocardial dysfunction or ongoing hypoperfusion despite adequate blood pressure; it is not first-line for isolated vasodilatory septic shock."
            },
            {
              "id": "B",
              "text": "Option A: Albumin infusion is inappropriate because albumin can be considered in selected patients who need large volumes of crystalloid, but it is not the preferred next pharmacologic step when shock persists after initial fluid resuscitation."
            },
            {
              "id": "C",
              "text": "Option C: Hydrocortisone can be added in refractory septic shock despite fluids and vasopressors, but vasopressor therapy should be started first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dobutamine infusion is inappropriate because dobutamine is primarily an inotrope for patients with myocardial dysfunction or ongoing hypoperfusion despite adequate blood pressure; it is not first-line for isolated vasodilatory septic shock."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hydrocortisone can be added in refractory septic shock despite fluids and vasopressors, but vasopressor therapy should be started first."
            },
            {
              "id": "B",
              "text": "Option A: Albumin infusion is inappropriate because albumin can be considered in selected patients who need large volumes of crystalloid, but it is not the preferred next pharmacologic step when shock persists after initial fluid resuscitation."
            },
            {
              "id": "C",
              "text": "Option B: Dobutamine infusion is inappropriate because dobutamine is primarily an inotrope for patients with myocardial dysfunction or ongoing hypoperfusion despite adequate blood pressure; it is not first-line for isolated vasodilatory septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hydrocortisone can be added in refractory septic shock despite fluids and vasopressors, but vasopressor therapy should be started first."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Phenylephrine infusion is inappropriate because phenylephrine is generally avoided as initial therapy in septic shock because pure alpha-agonism can reduce stroke volume and splanchnic perfusion compared with norepinephrine."
            },
            {
              "id": "B",
              "text": "Option A: Albumin infusion is inappropriate because albumin can be considered in selected patients who need large volumes of crystalloid, but it is not the preferred next pharmacologic step when shock persists after initial fluid resuscitation."
            },
            {
              "id": "C",
              "text": "Option B: Dobutamine infusion is inappropriate because dobutamine is primarily an inotrope for patients with myocardial dysfunction or ongoing hypoperfusion despite adequate blood pressure; it is not first-line for isolated vasodilatory septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Phenylephrine infusion is inappropriate because phenylephrine is generally avoided as initial therapy in septic shock because pure alpha-agonism can reduce stroke volume and splanchnic perfusion compared with norepinephrine."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sodium bicarbonate infusion is inappropriate because sodium bicarbonate does not address the hemodynamic collapse here and is not indicated for this degree of lactic acidosis in septic shock."
            },
            {
              "id": "B",
              "text": "Option A: Albumin infusion is inappropriate because albumin can be considered in selected patients who need large volumes of crystalloid, but it is not the preferred next pharmacologic step when shock persists after initial fluid resuscitation."
            },
            {
              "id": "C",
              "text": "Option B: Dobutamine infusion is inappropriate because dobutamine is primarily an inotrope for patients with myocardial dysfunction or ongoing hypoperfusion despite adequate blood pressure; it is not first-line for isolated vasodilatory septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sodium bicarbonate infusion is inappropriate because sodium bicarbonate does not address the hemodynamic collapse here and is not indicated for this degree of lactic acidosis in septic shock."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vasopressin as the sole initial vasopressor is inappropriate because vasopressin may be added to norepinephrine in septic shock, but it is not used as the sole initial vasopressor."
            },
            {
              "id": "B",
              "text": "Option A: Albumin infusion is inappropriate because albumin can be considered in selected patients who need large volumes of crystalloid, but it is not the preferred next pharmacologic step when shock persists after initial fluid resuscitation."
            },
            {
              "id": "C",
              "text": "Option B: Dobutamine infusion is inappropriate because dobutamine is primarily an inotrope for patients with myocardial dysfunction or ongoing hypoperfusion despite adequate blood pressure; it is not first-line for isolated vasodilatory septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vasopressin as the sole initial vasopressor is inappropriate because vasopressin may be added to norepinephrine in septic shock, but it is not used as the sole initial vasopressor."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i021-panic-disorder-family-history-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "dada3d3d55733ea3b53abf46c54746d097d87f6d5dea1bef3caddcd8ef1cca1b",
        "ranaze_step3_prd": "dada3d3d55733ea3b53abf46c54746d097d87f6d5dea1bef3caddcd8ef1cca1b"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Childhood repair of a congenital heart defect is inappropriate because congenital heart disease can complicate cardiac evaluation of palpitations or chest symptoms but is not a major susceptibility factor for panic disorder."
            },
            {
              "id": "B",
              "text": "Option C: Autoimmune hypothyroidism with a normal TSH concentration is inappropriate because untreated hyperthyroidism can mimic panic symptoms, but euthyroid autoimmune hypothyroidism does not meaningfully increase susceptibility to panic disorder."
            },
            {
              "id": "C",
              "text": "Option D: Recent relationship separation is inappropriate because relationship stress may precipitate symptom expression, but it is not the strongest predisposition factor listed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Childhood repair of a congenital heart defect is inappropriate because congenital heart disease can complicate cardiac evaluation of palpitations or chest symptoms but is not a major susceptibility factor for panic disorder."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Autoimmune hypothyroidism with a normal TSH concentration is inappropriate because untreated hyperthyroidism can mimic panic symptoms, but euthyroid autoimmune hypothyroidism does not meaningfully increase susceptibility to panic disorder."
            },
            {
              "id": "B",
              "text": "Option B: Childhood repair of a congenital heart defect is inappropriate because congenital heart disease can complicate cardiac evaluation of palpitations or chest symptoms but is not a major susceptibility factor for panic disorder."
            },
            {
              "id": "C",
              "text": "Option D: Recent relationship separation is inappropriate because relationship stress may precipitate symptom expression, but it is not the strongest predisposition factor listed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Autoimmune hypothyroidism with a normal TSH concentration is inappropriate because untreated hyperthyroidism can mimic panic symptoms, but euthyroid autoimmune hypothyroidism does not meaningfully increase susceptibility to panic disorder."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recent relationship separation is inappropriate because relationship stress may precipitate symptom expression, but it is not the strongest predisposition factor listed."
            },
            {
              "id": "B",
              "text": "Option B: Childhood repair of a congenital heart defect is inappropriate because congenital heart disease can complicate cardiac evaluation of palpitations or chest symptoms but is not a major susceptibility factor for panic disorder."
            },
            {
              "id": "C",
              "text": "Option C: Autoimmune hypothyroidism with a normal TSH concentration is inappropriate because untreated hyperthyroidism can mimic panic symptoms, but euthyroid autoimmune hypothyroidism does not meaningfully increase susceptibility to panic disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recent relationship separation is inappropriate because relationship stress may precipitate symptom expression, but it is not the strongest predisposition factor listed."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Daily commuting on crowded public transportation is inappropriate because crowded trains can become avoided situations after panic develops, but commuting itself is not a core susceptibility factor."
            },
            {
              "id": "B",
              "text": "Option B: Childhood repair of a congenital heart defect is inappropriate because congenital heart disease can complicate cardiac evaluation of palpitations or chest symptoms but is not a major susceptibility factor for panic disorder."
            },
            {
              "id": "C",
              "text": "Option C: Autoimmune hypothyroidism with a normal TSH concentration is inappropriate because untreated hyperthyroidism can mimic panic symptoms, but euthyroid autoimmune hypothyroidism does not meaningfully increase susceptibility to panic disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Daily commuting on crowded public transportation is inappropriate because crowded trains can become avoided situations after panic develops, but commuting itself is not a core susceptibility factor."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Occasional weekend alcohol use is inappropriate because occasional alcohol use does not explain increased baseline vulnerability to panic disorder."
            },
            {
              "id": "B",
              "text": "Option B: Childhood repair of a congenital heart defect is inappropriate because congenital heart disease can complicate cardiac evaluation of palpitations or chest symptoms but is not a major susceptibility factor for panic disorder."
            },
            {
              "id": "C",
              "text": "Option C: Autoimmune hypothyroidism with a normal TSH concentration is inappropriate because untreated hyperthyroidism can mimic panic symptoms, but euthyroid autoimmune hypothyroidism does not meaningfully increase susceptibility to panic disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Occasional weekend alcohol use is inappropriate because occasional alcohol use does not explain increased baseline vulnerability to panic disorder."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Avoidance of the train after the episodes began is inappropriate because avoidance behavior is a consequence of panic disorder, not a preexisting risk factor for developing it."
            },
            {
              "id": "B",
              "text": "Option B: Childhood repair of a congenital heart defect is inappropriate because congenital heart disease can complicate cardiac evaluation of palpitations or chest symptoms but is not a major susceptibility factor for panic disorder."
            },
            {
              "id": "C",
              "text": "Option C: Autoimmune hypothyroidism with a normal TSH concentration is inappropriate because untreated hyperthyroidism can mimic panic symptoms, but euthyroid autoimmune hypothyroidism does not meaningfully increase susceptibility to panic disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Avoidance of the train after the episodes began is inappropriate because avoidance behavior is a consequence of panic disorder, not a preexisting risk factor for developing it."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i024-atopic-eosinophilic-gastritis",
      "expectedHashes": {
        "ranaze_step3_uat": "a150056de61be1e15622a38d5a87a8c7fa71facb2c4087a6215e6d65634daeab",
        "ranaze_step3_prd": "a150056de61be1e15622a38d5a87a8c7fa71facb2c4087a6215e6d65634daeab"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Autoimmune metaplastic atrophic gastritis can cause anemia, but it does not fit the marked atopic history, elevated IgE, and dense eosinophilic gastric infiltrates."
            },
            {
              "id": "B",
              "text": "Option B: Crohn disease involving the stomach is inappropriate because crohn disease can affect any part of the gastrointestinal tract, but eosinophil-predominant gastric biopsies with strong atopic features point elsewhere."
            },
            {
              "id": "C",
              "text": "Option C: IgE-mediated food allergy without tissue disease is inappropriate because igE-mediated food allergy alone does not account for chronic gastrointestinal symptoms with biopsy-proven eosinophilic tissue infiltration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Autoimmune metaplastic atrophic gastritis can cause anemia, but it does not fit the marked atopic history, elevated IgE, and dense eosinophilic gastric infiltrates."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Crohn disease involving the stomach is inappropriate because crohn disease can affect any part of the gastrointestinal tract, but eosinophil-predominant gastric biopsies with strong atopic features point elsewhere."
            },
            {
              "id": "B",
              "text": "Option A: Autoimmune metaplastic atrophic gastritis can cause anemia, but it does not fit the marked atopic history, elevated IgE, and dense eosinophilic gastric infiltrates."
            },
            {
              "id": "C",
              "text": "Option C: IgE-mediated food allergy without tissue disease is inappropriate because igE-mediated food allergy alone does not account for chronic gastrointestinal symptoms with biopsy-proven eosinophilic tissue infiltration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Crohn disease involving the stomach is inappropriate because crohn disease can affect any part of the gastrointestinal tract, but eosinophil-predominant gastric biopsies with strong atopic features point elsewhere."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "IgE-mediated food allergy without tissue disease is inappropriate because igE-mediated food allergy alone does not account for chronic gastrointestinal symptoms with biopsy-proven eosinophilic tissue infiltration."
            },
            {
              "id": "B",
              "text": "Option A: Autoimmune metaplastic atrophic gastritis can cause anemia, but it does not fit the marked atopic history, elevated IgE, and dense eosinophilic gastric infiltrates."
            },
            {
              "id": "C",
              "text": "Option B: Crohn disease involving the stomach is inappropriate because crohn disease can affect any part of the gastrointestinal tract, but eosinophil-predominant gastric biopsies with strong atopic features point elsewhere."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "IgE-mediated food allergy without tissue disease is inappropriate because igE-mediated food allergy alone does not account for chronic gastrointestinal symptoms with biopsy-proven eosinophilic tissue infiltration."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Giardiasis can cause diarrhea and weight loss, but stool testing is negative and the biopsy findings are not typical for Giardia infection."
            },
            {
              "id": "B",
              "text": "Option A: Autoimmune metaplastic atrophic gastritis can cause anemia, but it does not fit the marked atopic history, elevated IgE, and dense eosinophilic gastric infiltrates."
            },
            {
              "id": "C",
              "text": "Option B: Crohn disease involving the stomach is inappropriate because crohn disease can affect any part of the gastrointestinal tract, but eosinophil-predominant gastric biopsies with strong atopic features point elsewhere."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Giardiasis can cause diarrhea and weight loss, but stool testing is negative and the biopsy findings are not typical for Giardia infection."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Helicobacter pylori peptic ulcer disease is less likely because gastric biopsies do not show Helicobacter organisms and instead show dense eosinophilic infiltration."
            },
            {
              "id": "B",
              "text": "Option A: Autoimmune metaplastic atrophic gastritis can cause anemia, but it does not fit the marked atopic history, elevated IgE, and dense eosinophilic gastric infiltrates."
            },
            {
              "id": "C",
              "text": "Option B: Crohn disease involving the stomach is inappropriate because crohn disease can affect any part of the gastrointestinal tract, but eosinophil-predominant gastric biopsies with strong atopic features point elsewhere."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Helicobacter pylori peptic ulcer disease is less likely because gastric biopsies do not show Helicobacter organisms and instead show dense eosinophilic infiltration."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Zollinger-Ellison syndrome causes acid hypersecretion and ulcer disease, not eosinophil-rich gastric inflammation in an atopic patient."
            },
            {
              "id": "B",
              "text": "Option A: Autoimmune metaplastic atrophic gastritis can cause anemia, but it does not fit the marked atopic history, elevated IgE, and dense eosinophilic gastric infiltrates."
            },
            {
              "id": "C",
              "text": "Option B: Crohn disease involving the stomach is inappropriate because crohn disease can affect any part of the gastrointestinal tract, but eosinophil-predominant gastric biopsies with strong atopic features point elsewhere."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Zollinger-Ellison syndrome causes acid hypersecretion and ulcer disease, not eosinophil-rich gastric inflammation in an atopic patient."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i025-older-man-epididymitis-ecoli",
      "expectedHashes": {
        "ranaze_step3_uat": "de3b1023c8223b1fa5af93476a04bb4ca1a6361fc1aa48af33e5e3b9d2c009f8",
        "ranaze_step3_prd": "de3b1023c8223b1fa5af93476a04bb4ca1a6361fc1aa48af33e5e3b9d2c009f8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chlamydia trachomatis is a common cause of epididymitis in younger sexually active patients, which does not fit this history."
            },
            {
              "id": "B",
              "text": "Option C: Herpes simplex virus type 2 causes painful vesicular genital lesions, not typical bacterial epididymitis with nitrites and pyuria."
            },
            {
              "id": "C",
              "text": "Option D: Mumps virus can cause orchitis, especially with parotitis, but this case localizes to the epididymis and suggests a urinary pathogen."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chlamydia trachomatis is a common cause of epididymitis in younger sexually active patients, which does not fit this history."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Herpes simplex virus type 2 causes painful vesicular genital lesions, not typical bacterial epididymitis with nitrites and pyuria."
            },
            {
              "id": "B",
              "text": "Option A: Chlamydia trachomatis is a common cause of epididymitis in younger sexually active patients, which does not fit this history."
            },
            {
              "id": "C",
              "text": "Option D: Mumps virus can cause orchitis, especially with parotitis, but this case localizes to the epididymis and suggests a urinary pathogen."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Herpes simplex virus type 2 causes painful vesicular genital lesions, not typical bacterial epididymitis with nitrites and pyuria."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mumps virus can cause orchitis, especially with parotitis, but this case localizes to the epididymis and suggests a urinary pathogen."
            },
            {
              "id": "B",
              "text": "Option A: Chlamydia trachomatis is a common cause of epididymitis in younger sexually active patients, which does not fit this history."
            },
            {
              "id": "C",
              "text": "Option C: Herpes simplex virus type 2 causes painful vesicular genital lesions, not typical bacterial epididymitis with nitrites and pyuria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mumps virus can cause orchitis, especially with parotitis, but this case localizes to the epididymis and suggests a urinary pathogen."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neisseria gonorrhoeae is more typical in younger sexually active patients with urethritis risk."
            },
            {
              "id": "B",
              "text": "Option A: Chlamydia trachomatis is a common cause of epididymitis in younger sexually active patients, which does not fit this history."
            },
            {
              "id": "C",
              "text": "Option C: Herpes simplex virus type 2 causes painful vesicular genital lesions, not typical bacterial epididymitis with nitrites and pyuria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neisseria gonorrhoeae is more typical in younger sexually active patients with urethritis risk."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treponema pallidum causes syphilis, which does not present as this pattern of epididymal tenderness and urinary infection findings."
            },
            {
              "id": "B",
              "text": "Option A: Chlamydia trachomatis is a common cause of epididymitis in younger sexually active patients, which does not fit this history."
            },
            {
              "id": "C",
              "text": "Option C: Herpes simplex virus type 2 causes painful vesicular genital lesions, not typical bacterial epididymitis with nitrites and pyuria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treponema pallidum causes syphilis, which does not present as this pattern of epididymal tenderness and urinary infection findings."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ureaplasma urealyticum can be associated with nongonococcal urethritis, but it is not the classic cause in this older man with urinary tract risk factors."
            },
            {
              "id": "B",
              "text": "Option A: Chlamydia trachomatis is a common cause of epididymitis in younger sexually active patients, which does not fit this history."
            },
            {
              "id": "C",
              "text": "Option C: Herpes simplex virus type 2 causes painful vesicular genital lesions, not typical bacterial epididymitis with nitrites and pyuria."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ureaplasma urealyticum can be associated with nongonococcal urethritis, but it is not the classic cause in this older man with urinary tract risk factors."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i026-congenital-hyperinsulinism-persistent-insulin",
      "expectedHashes": {
        "ranaze_step3_uat": "330c0e894a2505cebe9625787056ff8293ac40b682ec2a959119f67b16a2eaf1",
        "ranaze_step3_prd": "330c0e894a2505cebe9625787056ff8293ac40b682ec2a959119f67b16a2eaf1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Marked elevation of beta-hydroxybutyrate during hypoglycemia is inappropriate because elevated beta-hydroxybutyrate would argue against insulin excess because insulin suppresses ketogenesis during hypoglycemia."
            },
            {
              "id": "B",
              "text": "Option B: Increased free fatty acid concentration during hypoglycemia is inappropriate because free fatty acids are typically suppressed, not increased, when excess insulin is driving hypoglycemia."
            },
            {
              "id": "C",
              "text": "Option D: Undetectable C-peptide concentration during hypoglycemia is inappropriate because undetectable C-peptide suggests exogenous insulin exposure rather than endogenous pancreatic hypersecretion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Marked elevation of beta-hydroxybutyrate during hypoglycemia is inappropriate because elevated beta-hydroxybutyrate would argue against insulin excess because insulin suppresses ketogenesis during hypoglycemia."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased free fatty acid concentration during hypoglycemia is inappropriate because free fatty acids are typically suppressed, not increased, when excess insulin is driving hypoglycemia."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of beta-hydroxybutyrate during hypoglycemia is inappropriate because elevated beta-hydroxybutyrate would argue against insulin excess because insulin suppresses ketogenesis during hypoglycemia."
            },
            {
              "id": "C",
              "text": "Option D: Undetectable C-peptide concentration during hypoglycemia is inappropriate because undetectable C-peptide suggests exogenous insulin exposure rather than endogenous pancreatic hypersecretion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased free fatty acid concentration during hypoglycemia is inappropriate because free fatty acids are typically suppressed, not increased, when excess insulin is driving hypoglycemia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Undetectable C-peptide concentration during hypoglycemia is inappropriate because undetectable C-peptide suggests exogenous insulin exposure rather than endogenous pancreatic hypersecretion."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of beta-hydroxybutyrate during hypoglycemia is inappropriate because elevated beta-hydroxybutyrate would argue against insulin excess because insulin suppresses ketogenesis during hypoglycemia."
            },
            {
              "id": "C",
              "text": "Option B: Increased free fatty acid concentration during hypoglycemia is inappropriate because free fatty acids are typically suppressed, not increased, when excess insulin is driving hypoglycemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Undetectable C-peptide concentration during hypoglycemia is inappropriate because undetectable C-peptide suggests exogenous insulin exposure rather than endogenous pancreatic hypersecretion."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Worsening hypoglycemia after diazoxide administration is inappropriate because diazoxide usually improves many forms of congenital hyperinsulinism; worsening after administration would not fit this pattern."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of beta-hydroxybutyrate during hypoglycemia is inappropriate because elevated beta-hydroxybutyrate would argue against insulin excess because insulin suppresses ketogenesis during hypoglycemia."
            },
            {
              "id": "C",
              "text": "Option B: Increased free fatty acid concentration during hypoglycemia is inappropriate because free fatty acids are typically suppressed, not increased, when excess insulin is driving hypoglycemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Worsening hypoglycemia after diazoxide administration is inappropriate because diazoxide usually improves many forms of congenital hyperinsulinism; worsening after administration would not fit this pattern."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Glucose infusion requirement below normal neonatal needs is inappropriate because these infants usually need abnormally high, not low, glucose infusion rates to prevent recurrent hypoglycemia."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of beta-hydroxybutyrate during hypoglycemia is inappropriate because elevated beta-hydroxybutyrate would argue against insulin excess because insulin suppresses ketogenesis during hypoglycemia."
            },
            {
              "id": "C",
              "text": "Option B: Increased free fatty acid concentration during hypoglycemia is inappropriate because free fatty acids are typically suppressed, not increased, when excess insulin is driving hypoglycemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Glucose infusion requirement below normal neonatal needs is inappropriate because these infants usually need abnormally high, not low, glucose infusion rates to prevent recurrent hypoglycemia."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ability to fast overnight without symptoms by 1 month of age is inappropriate because improved prolonged fasting tolerance would be unexpected in an infant with ongoing pathologic insulin secretion."
            },
            {
              "id": "B",
              "text": "Option A: Marked elevation of beta-hydroxybutyrate during hypoglycemia is inappropriate because elevated beta-hydroxybutyrate would argue against insulin excess because insulin suppresses ketogenesis during hypoglycemia."
            },
            {
              "id": "C",
              "text": "Option B: Increased free fatty acid concentration during hypoglycemia is inappropriate because free fatty acids are typically suppressed, not increased, when excess insulin is driving hypoglycemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ability to fast overnight without symptoms by 1 month of age is inappropriate because improved prolonged fasting tolerance would be unexpected in an infant with ongoing pathologic insulin secretion."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i028-uterine-duplication-pregnancy-loss-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "324459d8cb8d85fbd85933f90b5f10ae71c1918fa292c5eb7652292c266daada",
        "ranaze_step3_prd": "324459d8cb8d85fbd85933f90b5f10ae71c1918fa292c5eb7652292c266daada"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Endometrial carcinoma is not the characteristic long-term complication of a congenital uterine duplication anomaly in this setting."
            },
            {
              "id": "B",
              "text": "Option B: Fetal macrosomia is associated with maternal diabetes, not a Mullerian fusion defect."
            },
            {
              "id": "C",
              "text": "Option C: Metabolic syndrome is unrelated to this structural reproductive tract anomaly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Endometrial carcinoma is not the characteristic long-term complication of a congenital uterine duplication anomaly in this setting."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fetal macrosomia is associated with maternal diabetes, not a Mullerian fusion defect."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial carcinoma is not the characteristic long-term complication of a congenital uterine duplication anomaly in this setting."
            },
            {
              "id": "C",
              "text": "Option C: Metabolic syndrome is unrelated to this structural reproductive tract anomaly."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fetal macrosomia is associated with maternal diabetes, not a Mullerian fusion defect."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Metabolic syndrome is unrelated to this structural reproductive tract anomaly."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial carcinoma is not the characteristic long-term complication of a congenital uterine duplication anomaly in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Fetal macrosomia is associated with maternal diabetes, not a Mullerian fusion defect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Metabolic syndrome is unrelated to this structural reproductive tract anomaly."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patients with uterus didelphys often can conceive, so primary infertility is less characteristic than pregnancy loss."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial carcinoma is not the characteristic long-term complication of a congenital uterine duplication anomaly in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Fetal macrosomia is associated with maternal diabetes, not a Mullerian fusion defect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patients with uterus didelphys often can conceive, so primary infertility is less characteristic than pregnancy loss."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tubal ectopic pregnancy as the typical outcome is inappropriate because ectopic pregnancy can occur in many patients of reproductive age, but it is not the most characteristic complication of this anomaly."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial carcinoma is not the characteristic long-term complication of a congenital uterine duplication anomaly in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Fetal macrosomia is associated with maternal diabetes, not a Mullerian fusion defect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tubal ectopic pregnancy as the typical outcome is inappropriate because ectopic pregnancy can occur in many patients of reproductive age, but it is not the most characteristic complication of this anomaly."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Premature ovarian insufficiency involves ovarian dysfunction, not duplication of the uterus and cervix."
            },
            {
              "id": "B",
              "text": "Option A: Endometrial carcinoma is not the characteristic long-term complication of a congenital uterine duplication anomaly in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Fetal macrosomia is associated with maternal diabetes, not a Mullerian fusion defect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Premature ovarian insufficiency involves ovarian dysfunction, not duplication of the uterus and cervix."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i033-impaired-physician-reporting",
      "expectedHashes": {
        "ranaze_step3_uat": "262e8d8d079c92e754bf889145a6dd4c73c84289619ea93eced921beb9860e5a",
        "ranaze_step3_prd": "262e8d8d079c92e754bf889145a6dd4c73c84289619ea93eced921beb9860e5a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Advise this patient to sue the endocrinologist is inappropriate because encouraging litigation does not fulfill the physician\u0027s professional duty to protect future patients from an impaired or dangerous practitioner."
            },
            {
              "id": "B",
              "text": "Option B: Discuss the concern with hospital administration first is inappropriate because hospital administration may not have jurisdiction over an outpatient specialist\u0027s license; the appropriate formal reporting body is the state medical board."
            },
            {
              "id": "C",
              "text": "Option C: Refuse to accept any additional shared patients from that endocrinologist is inappropriate because avoiding future shared care does not address the ongoing danger to other patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Advise this patient to sue the endocrinologist is inappropriate because encouraging litigation does not fulfill the physician\u0027s professional duty to protect future patients from an impaired or dangerous practitioner."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discuss the concern with hospital administration first is inappropriate because hospital administration may not have jurisdiction over an outpatient specialist\u0027s license; the appropriate formal reporting body is the state medical board."
            },
            {
              "id": "B",
              "text": "Option A: Advise this patient to sue the endocrinologist is inappropriate because encouraging litigation does not fulfill the physician\u0027s professional duty to protect future patients from an impaired or dangerous practitioner."
            },
            {
              "id": "C",
              "text": "Option C: Refuse to accept any additional shared patients from that endocrinologist is inappropriate because avoiding future shared care does not address the ongoing danger to other patients."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discuss the concern with hospital administration first is inappropriate because hospital administration may not have jurisdiction over an outpatient specialist\u0027s license; the appropriate formal reporting body is the state medical board."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refuse to accept any additional shared patients from that endocrinologist is inappropriate because avoiding future shared care does not address the ongoing danger to other patients."
            },
            {
              "id": "B",
              "text": "Option A: Advise this patient to sue the endocrinologist is inappropriate because encouraging litigation does not fulfill the physician\u0027s professional duty to protect future patients from an impaired or dangerous practitioner."
            },
            {
              "id": "C",
              "text": "Option B: Discuss the concern with hospital administration first is inappropriate because hospital administration may not have jurisdiction over an outpatient specialist\u0027s license; the appropriate formal reporting body is the state medical board."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refuse to accept any additional shared patients from that endocrinologist is inappropriate because avoiding future shared care does not address the ongoing danger to other patients."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfer all records to the endocrinologist and end co-management is inappropriate because ending co-management does not protect other patients and does not meet the duty to report serious professional misconduct."
            },
            {
              "id": "B",
              "text": "Option A: Advise this patient to sue the endocrinologist is inappropriate because encouraging litigation does not fulfill the physician\u0027s professional duty to protect future patients from an impaired or dangerous practitioner."
            },
            {
              "id": "C",
              "text": "Option B: Discuss the concern with hospital administration first is inappropriate because hospital administration may not have jurisdiction over an outpatient specialist\u0027s license; the appropriate formal reporting body is the state medical board."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfer all records to the endocrinologist and end co-management is inappropriate because ending co-management does not protect other patients and does not meet the duty to report serious professional misconduct."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the patient to report the endocrinologist to the state medical board is inappropriate because the responsibility to report serious physician misconduct lies with the physician who has direct knowledge, not the patient."
            },
            {
              "id": "B",
              "text": "Option A: Advise this patient to sue the endocrinologist is inappropriate because encouraging litigation does not fulfill the physician\u0027s professional duty to protect future patients from an impaired or dangerous practitioner."
            },
            {
              "id": "C",
              "text": "Option B: Discuss the concern with hospital administration first is inappropriate because hospital administration may not have jurisdiction over an outpatient specialist\u0027s license; the appropriate formal reporting body is the state medical board."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the patient to report the endocrinologist to the state medical board is inappropriate because the responsibility to report serious physician misconduct lies with the physician who has direct knowledge, not the patient."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Call the endocrinologist privately and take no further action unless another event occurs is inappropriate because a private conversation alone is inadequate when there is a pattern of behavior causing substantial patient harm."
            },
            {
              "id": "B",
              "text": "Option A: Advise this patient to sue the endocrinologist is inappropriate because encouraging litigation does not fulfill the physician\u0027s professional duty to protect future patients from an impaired or dangerous practitioner."
            },
            {
              "id": "C",
              "text": "Option B: Discuss the concern with hospital administration first is inappropriate because hospital administration may not have jurisdiction over an outpatient specialist\u0027s license; the appropriate formal reporting body is the state medical board."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Call the endocrinologist privately and take no further action unless another event occurs is inappropriate because a private conversation alone is inadequate when there is a pattern of behavior causing substantial patient harm."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i034-adolescent-vaccine-catchup",
      "expectedHashes": {
        "ranaze_step3_uat": "939698a8b3f8707676f59c20f63a1f427c241ba58d778c3182479f366734f6f8",
        "ranaze_step3_prd": "939698a8b3f8707676f59c20f63a1f427c241ba58d778c3182479f366734f6f8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer Haemophilus influenzae type b vaccine is inappropriate because haemophilus influenzae type b vaccine is not routinely given to healthy adolescents who completed infancy and early childhood care; catch-up use is generally limited to selected high-risk patients."
            },
            {
              "id": "B",
              "text": "Option B: Administer a hepatitis A vaccine dose is inappropriate because an additional hepatitis A dose is not indicated after a completed 2-dose series."
            },
            {
              "id": "C",
              "text": "Option C: Administer a hepatitis B vaccine dose is inappropriate because an additional hepatitis B dose is not indicated after a completed primary series."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer Haemophilus influenzae type b vaccine is inappropriate because haemophilus influenzae type b vaccine is not routinely given to healthy adolescents who completed infancy and early childhood care; catch-up use is generally limited to selected high-risk patients."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a hepatitis A vaccine dose is inappropriate because an additional hepatitis A dose is not indicated after a completed 2-dose series."
            },
            {
              "id": "B",
              "text": "Option A: Administer Haemophilus influenzae type b vaccine is inappropriate because haemophilus influenzae type b vaccine is not routinely given to healthy adolescents who completed infancy and early childhood care; catch-up use is generally limited to selected high-risk patients."
            },
            {
              "id": "C",
              "text": "Option C: Administer a hepatitis B vaccine dose is inappropriate because an additional hepatitis B dose is not indicated after a completed primary series."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a hepatitis A vaccine dose is inappropriate because an additional hepatitis A dose is not indicated after a completed 2-dose series."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a hepatitis B vaccine dose is inappropriate because an additional hepatitis B dose is not indicated after a completed primary series."
            },
            {
              "id": "B",
              "text": "Option A: Administer Haemophilus influenzae type b vaccine is inappropriate because haemophilus influenzae type b vaccine is not routinely given to healthy adolescents who completed infancy and early childhood care; catch-up use is generally limited to selected high-risk patients."
            },
            {
              "id": "C",
              "text": "Option B: Administer a hepatitis A vaccine dose is inappropriate because an additional hepatitis A dose is not indicated after a completed 2-dose series."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a hepatitis B vaccine dose is inappropriate because an additional hepatitis B dose is not indicated after a completed primary series."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer an inactivated poliovirus vaccine dose is inappropriate because an additional IPV dose is not indicated after a completed 4-dose poliovirus series in a healthy adolescent."
            },
            {
              "id": "B",
              "text": "Option A: Administer Haemophilus influenzae type b vaccine is inappropriate because haemophilus influenzae type b vaccine is not routinely given to healthy adolescents who completed infancy and early childhood care; catch-up use is generally limited to selected high-risk patients."
            },
            {
              "id": "C",
              "text": "Option B: Administer a hepatitis A vaccine dose is inappropriate because an additional hepatitis A dose is not indicated after a completed 2-dose series."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer an inactivated poliovirus vaccine dose is inappropriate because an additional IPV dose is not indicated after a completed 4-dose poliovirus series in a healthy adolescent."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a rotavirus vaccine dose is inappropriate because rotavirus vaccine is given only in infancy and is not started or continued in adolescents."
            },
            {
              "id": "B",
              "text": "Option A: Administer Haemophilus influenzae type b vaccine is inappropriate because haemophilus influenzae type b vaccine is not routinely given to healthy adolescents who completed infancy and early childhood care; catch-up use is generally limited to selected high-risk patients."
            },
            {
              "id": "C",
              "text": "Option B: Administer a hepatitis A vaccine dose is inappropriate because an additional hepatitis A dose is not indicated after a completed 2-dose series."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a rotavirus vaccine dose is inappropriate because rotavirus vaccine is given only in infancy and is not started or continued in adolescents."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a pneumococcal conjugate vaccine dose is inappropriate because routine pneumococcal conjugate vaccination is not recommended for a healthy adolescent without specific medical risk factors."
            },
            {
              "id": "B",
              "text": "Option A: Administer Haemophilus influenzae type b vaccine is inappropriate because haemophilus influenzae type b vaccine is not routinely given to healthy adolescents who completed infancy and early childhood care; catch-up use is generally limited to selected high-risk patients."
            },
            {
              "id": "C",
              "text": "Option B: Administer a hepatitis A vaccine dose is inappropriate because an additional hepatitis A dose is not indicated after a completed 2-dose series."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a pneumococcal conjugate vaccine dose is inappropriate because routine pneumococcal conjugate vaccination is not recommended for a healthy adolescent without specific medical risk factors."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i037-rosacea-clinical-diagnosis",
      "expectedHashes": {
        "ranaze_step3_uat": "194543602cf34cea420d8fe3dfa98f432ad6ffbc51a6f44e3a8f1ec3d09c2c58",
        "ranaze_step3_prd": "194543602cf34cea420d8fe3dfa98f432ad6ffbc51a6f44e3a8f1ec3d09c2c58"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum antinuclear antibody testing is inappropriate because aNA testing is not indicated for a classic rosacea presentation without features suggesting connective tissue disease."
            },
            {
              "id": "B",
              "text": "Option B: Punch biopsy of the facial skin is inappropriate because skin biopsy is unnecessary when the morphology and triggers are typical for rosacea."
            },
            {
              "id": "C",
              "text": "Option C: Skin-prick allergy testing is inappropriate because allergy testing does not evaluate this chronic vascular-inflammatory facial disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum antinuclear antibody testing is inappropriate because aNA testing is not indicated for a classic rosacea presentation without features suggesting connective tissue disease."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Punch biopsy of the facial skin is inappropriate because skin biopsy is unnecessary when the morphology and triggers are typical for rosacea."
            },
            {
              "id": "B",
              "text": "Option A: Serum antinuclear antibody testing is inappropriate because aNA testing is not indicated for a classic rosacea presentation without features suggesting connective tissue disease."
            },
            {
              "id": "C",
              "text": "Option C: Skin-prick allergy testing is inappropriate because allergy testing does not evaluate this chronic vascular-inflammatory facial disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Punch biopsy of the facial skin is inappropriate because skin biopsy is unnecessary when the morphology and triggers are typical for rosacea."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Skin-prick allergy testing is inappropriate because allergy testing does not evaluate this chronic vascular-inflammatory facial disorder."
            },
            {
              "id": "B",
              "text": "Option A: Serum antinuclear antibody testing is inappropriate because aNA testing is not indicated for a classic rosacea presentation without features suggesting connective tissue disease."
            },
            {
              "id": "C",
              "text": "Option B: Punch biopsy of the facial skin is inappropriate because skin biopsy is unnecessary when the morphology and triggers are typical for rosacea."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Skin-prick allergy testing is inappropriate because allergy testing does not evaluate this chronic vascular-inflammatory facial disorder."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bacterial culture of a papule is inappropriate because routine bacterial culture is not indicated for typical rosacea papules."
            },
            {
              "id": "B",
              "text": "Option A: Serum antinuclear antibody testing is inappropriate because aNA testing is not indicated for a classic rosacea presentation without features suggesting connective tissue disease."
            },
            {
              "id": "C",
              "text": "Option B: Punch biopsy of the facial skin is inappropriate because skin biopsy is unnecessary when the morphology and triggers are typical for rosacea."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bacterial culture of a papule is inappropriate because routine bacterial culture is not indicated for typical rosacea papules."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum rheumatoid factor testing is inappropriate because rheumatoid factor testing is not useful in a patient with no inflammatory arthritis features and a classic facial rosacea pattern."
            },
            {
              "id": "B",
              "text": "Option A: Serum antinuclear antibody testing is inappropriate because aNA testing is not indicated for a classic rosacea presentation without features suggesting connective tissue disease."
            },
            {
              "id": "C",
              "text": "Option B: Punch biopsy of the facial skin is inappropriate because skin biopsy is unnecessary when the morphology and triggers are typical for rosacea."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum rheumatoid factor testing is inappropriate because rheumatoid factor testing is not useful in a patient with no inflammatory arthritis features and a classic facial rosacea pattern."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "24-hour urine 5-hydroxyindoleacetic acid measurement is inappropriate because urine 5-HIAA is used when carcinoid syndrome is suspected, which is not supported by this isolated chronic facial eruption."
            },
            {
              "id": "B",
              "text": "Option A: Serum antinuclear antibody testing is inappropriate because aNA testing is not indicated for a classic rosacea presentation without features suggesting connective tissue disease."
            },
            {
              "id": "C",
              "text": "Option B: Punch biopsy of the facial skin is inappropriate because skin biopsy is unnecessary when the morphology and triggers are typical for rosacea."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "24-hour urine 5-hydroxyindoleacetic acid measurement is inappropriate because urine 5-HIAA is used when carcinoid syndrome is suspected, which is not supported by this isolated chronic facial eruption."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i039-primary-prevention-pneumococcal-vaccination",
      "expectedHashes": {
        "ranaze_step3_uat": "0c9790df0aa4f1b54a49378e22564fc53c73756493ece772ab4056478cff84ab",
        "ranaze_step3_prd": "0c9790df0aa4f1b54a49378e22564fc53c73756493ece772ab4056478cff84ab"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Annual dilated retinal examination is inappropriate because retinal examination is secondary prevention because it screens for diabetic eye disease rather than preventing it from occurring."
            },
            {
              "id": "B",
              "text": "Option B: Daily lisinopril therapy is inappropriate because lisinopril here is management of established disease and diabetic kidney involvement, not primary prevention."
            },
            {
              "id": "C",
              "text": "Option C: High-intensity statin therapy is inappropriate because in a patient with prior myocardial infarction, statin therapy is secondary prevention of further atherosclerotic events."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Annual dilated retinal examination is inappropriate because retinal examination is secondary prevention because it screens for diabetic eye disease rather than preventing it from occurring."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Daily lisinopril therapy is inappropriate because lisinopril here is management of established disease and diabetic kidney involvement, not primary prevention."
            },
            {
              "id": "B",
              "text": "Option A: Annual dilated retinal examination is inappropriate because retinal examination is secondary prevention because it screens for diabetic eye disease rather than preventing it from occurring."
            },
            {
              "id": "C",
              "text": "Option C: High-intensity statin therapy is inappropriate because in a patient with prior myocardial infarction, statin therapy is secondary prevention of further atherosclerotic events."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Daily lisinopril therapy is inappropriate because lisinopril here is management of established disease and diabetic kidney involvement, not primary prevention."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High-intensity statin therapy is inappropriate because in a patient with prior myocardial infarction, statin therapy is secondary prevention of further atherosclerotic events."
            },
            {
              "id": "B",
              "text": "Option A: Annual dilated retinal examination is inappropriate because retinal examination is secondary prevention because it screens for diabetic eye disease rather than preventing it from occurring."
            },
            {
              "id": "C",
              "text": "Option B: Daily lisinopril therapy is inappropriate because lisinopril here is management of established disease and diabetic kidney involvement, not primary prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High-intensity statin therapy is inappropriate because in a patient with prior myocardial infarction, statin therapy is secondary prevention of further atherosclerotic events."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Screening exercise electrocardiography is inappropriate because screening exercise ECG is not the best example of primary prevention and is not routinely recommended for this purpose."
            },
            {
              "id": "B",
              "text": "Option A: Annual dilated retinal examination is inappropriate because retinal examination is secondary prevention because it screens for diabetic eye disease rather than preventing it from occurring."
            },
            {
              "id": "C",
              "text": "Option B: Daily lisinopril therapy is inappropriate because lisinopril here is management of established disease and diabetic kidney involvement, not primary prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Screening exercise electrocardiography is inappropriate because screening exercise ECG is not the best example of primary prevention and is not routinely recommended for this purpose."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Yearly urine albumin monitoring is secondary prevention because it detects nephropathy rather than preventing the initial disease."
            },
            {
              "id": "B",
              "text": "Option A: Annual dilated retinal examination is inappropriate because retinal examination is secondary prevention because it screens for diabetic eye disease rather than preventing it from occurring."
            },
            {
              "id": "C",
              "text": "Option B: Daily lisinopril therapy is inappropriate because lisinopril here is management of established disease and diabetic kidney involvement, not primary prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Yearly urine albumin monitoring is secondary prevention because it detects nephropathy rather than preventing the initial disease."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Referral for podiatric management of sensory loss is inappropriate because podiatric management addresses an existing complication, so it is not primary prevention."
            },
            {
              "id": "B",
              "text": "Option A: Annual dilated retinal examination is inappropriate because retinal examination is secondary prevention because it screens for diabetic eye disease rather than preventing it from occurring."
            },
            {
              "id": "C",
              "text": "Option B: Daily lisinopril therapy is inappropriate because lisinopril here is management of established disease and diabetic kidney involvement, not primary prevention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Referral for podiatric management of sensory loss is inappropriate because podiatric management addresses an existing complication, so it is not primary prevention."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i040-hand-osteoarthritis-matrix-degradation",
      "expectedHashes": {
        "ranaze_step3_uat": "b8b5625068e96a6102f05806e5cdb3308597630dc8c0d1561e14c407723ff6a2",
        "ranaze_step3_prd": "b8b5625068e96a6102f05806e5cdb3308597630dc8c0d1561e14c407723ff6a2"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Autoantibody-driven synovial pannus formation with lymphoid aggregates describes rheumatoid arthritis, which typically affects MCP and PIP joints with prolonged morning stiffness rather than bony DIP enlargement and osteophytes."
            },
            {
              "id": "B",
              "text": "Option B: Deposition of calcium pyrophosphate crystals within articular cartilage is inappropriate because calcium pyrophosphate deposition can cause acute inflammatory arthritis or chondrocalcinosis, usually involving larger joints rather than this chronic nodal hand pattern."
            },
            {
              "id": "C",
              "text": "Option C: Acute bacterial invasion of the joint space with suppurative destruction is inappropriate because acute bacterial septic arthritis usually presents with a hot, markedly inflamed joint and systemic symptoms, not slowly progressive multijoint degenerative changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Autoantibody-driven synovial pannus formation with lymphoid aggregates describes rheumatoid arthritis, which typically affects MCP and PIP joints with prolonged morning stiffness rather than bony DIP enlargement and osteophytes."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Deposition of calcium pyrophosphate crystals within articular cartilage is inappropriate because calcium pyrophosphate deposition can cause acute inflammatory arthritis or chondrocalcinosis, usually involving larger joints rather than this chronic nodal hand pattern."
            },
            {
              "id": "B",
              "text": "Option A: Autoantibody-driven synovial pannus formation with lymphoid aggregates describes rheumatoid arthritis, which typically affects MCP and PIP joints with prolonged morning stiffness rather than bony DIP enlargement and osteophytes."
            },
            {
              "id": "C",
              "text": "Option C: Acute bacterial invasion of the joint space with suppurative destruction is inappropriate because acute bacterial septic arthritis usually presents with a hot, markedly inflamed joint and systemic symptoms, not slowly progressive multijoint degenerative changes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Deposition of calcium pyrophosphate crystals within articular cartilage is inappropriate because calcium pyrophosphate deposition can cause acute inflammatory arthritis or chondrocalcinosis, usually involving larger joints rather than this chronic nodal hand pattern."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute bacterial invasion of the joint space with suppurative destruction is inappropriate because acute bacterial septic arthritis usually presents with a hot, markedly inflamed joint and systemic symptoms, not slowly progressive multijoint degenerative changes."
            },
            {
              "id": "B",
              "text": "Option A: Autoantibody-driven synovial pannus formation with lymphoid aggregates describes rheumatoid arthritis, which typically affects MCP and PIP joints with prolonged morning stiffness rather than bony DIP enlargement and osteophytes."
            },
            {
              "id": "C",
              "text": "Option B: Deposition of calcium pyrophosphate crystals within articular cartilage is inappropriate because calcium pyrophosphate deposition can cause acute inflammatory arthritis or chondrocalcinosis, usually involving larger joints rather than this chronic nodal hand pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute bacterial invasion of the joint space with suppurative destruction is inappropriate because acute bacterial septic arthritis usually presents with a hot, markedly inflamed joint and systemic symptoms, not slowly progressive multijoint degenerative changes."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immune complex-mediated fibrinoid necrosis of periarticular vessels is inappropriate because immune complex-mediated fibrinoid necrosis is a vasculitic process and does not explain osteophytes, subchondral cysts, and chronic DIP/PIP degeneration."
            },
            {
              "id": "B",
              "text": "Option A: Autoantibody-driven synovial pannus formation with lymphoid aggregates describes rheumatoid arthritis, which typically affects MCP and PIP joints with prolonged morning stiffness rather than bony DIP enlargement and osteophytes."
            },
            {
              "id": "C",
              "text": "Option B: Deposition of calcium pyrophosphate crystals within articular cartilage is inappropriate because calcium pyrophosphate deposition can cause acute inflammatory arthritis or chondrocalcinosis, usually involving larger joints rather than this chronic nodal hand pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immune complex-mediated fibrinoid necrosis of periarticular vessels is inappropriate because immune complex-mediated fibrinoid necrosis is a vasculitic process and does not explain osteophytes, subchondral cysts, and chronic DIP/PIP degeneration."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Deposition of monosodium urate crystals in periarticular tissues is inappropriate because monosodium urate deposition causes gout, which presents with episodic inflammatory attacks rather than chronic osteoarthritic nodal changes of the fingers."
            },
            {
              "id": "B",
              "text": "Option A: Autoantibody-driven synovial pannus formation with lymphoid aggregates describes rheumatoid arthritis, which typically affects MCP and PIP joints with prolonged morning stiffness rather than bony DIP enlargement and osteophytes."
            },
            {
              "id": "C",
              "text": "Option B: Deposition of calcium pyrophosphate crystals within articular cartilage is inappropriate because calcium pyrophosphate deposition can cause acute inflammatory arthritis or chondrocalcinosis, usually involving larger joints rather than this chronic nodal hand pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Deposition of monosodium urate crystals in periarticular tissues is inappropriate because monosodium urate deposition causes gout, which presents with episodic inflammatory attacks rather than chronic osteoarthritic nodal changes of the fingers."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fibroblast proliferation causing diffuse skin thickening around the digits is inappropriate because fibroblast proliferation with skin thickening suggests systemic sclerosis, which does not produce the radiographic degenerative joint findings described here."
            },
            {
              "id": "B",
              "text": "Option A: Autoantibody-driven synovial pannus formation with lymphoid aggregates describes rheumatoid arthritis, which typically affects MCP and PIP joints with prolonged morning stiffness rather than bony DIP enlargement and osteophytes."
            },
            {
              "id": "C",
              "text": "Option B: Deposition of calcium pyrophosphate crystals within articular cartilage is inappropriate because calcium pyrophosphate deposition can cause acute inflammatory arthritis or chondrocalcinosis, usually involving larger joints rather than this chronic nodal hand pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fibroblast proliferation causing diffuse skin thickening around the digits is inappropriate because fibroblast proliferation with skin thickening suggests systemic sclerosis, which does not produce the radiographic degenerative joint findings described here."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i041-postoperative-central-diabetes-insipidus",
      "expectedHashes": {
        "ranaze_step3_uat": "9c0c02786692d5191c1d8c600ee014e14ddbbb3d0dfc1715bfc13eb95ad6ed8a",
        "ranaze_step3_prd": "9c0c02786692d5191c1d8c600ee014e14ddbbb3d0dfc1715bfc13eb95ad6ed8a"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a bolus of 3% saline is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not hypernatremia from free-water loss."
            },
            {
              "id": "B",
              "text": "Option B: Restrict oral fluids is inappropriate because fluid restriction would worsen hypernatremia in diabetes insipidus."
            },
            {
              "id": "C",
              "text": "Option D: Obtain an urgent noncontrast CT scan of the head is inappropriate because head CT is not the most appropriate next step when the presentation already strongly supports postoperative central diabetes insipidus without focal neurologic deterioration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a bolus of 3% saline is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not hypernatremia from free-water loss."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restrict oral fluids is inappropriate because fluid restriction would worsen hypernatremia in diabetes insipidus."
            },
            {
              "id": "B",
              "text": "Option A: Administer a bolus of 3% saline is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not hypernatremia from free-water loss."
            },
            {
              "id": "C",
              "text": "Option D: Obtain an urgent noncontrast CT scan of the head is inappropriate because head CT is not the most appropriate next step when the presentation already strongly supports postoperative central diabetes insipidus without focal neurologic deterioration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restrict oral fluids is inappropriate because fluid restriction would worsen hypernatremia in diabetes insipidus."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an urgent noncontrast CT scan of the head is inappropriate because head CT is not the most appropriate next step when the presentation already strongly supports postoperative central diabetes insipidus without focal neurologic deterioration."
            },
            {
              "id": "B",
              "text": "Option A: Administer a bolus of 3% saline is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not hypernatremia from free-water loss."
            },
            {
              "id": "C",
              "text": "Option B: Restrict oral fluids is inappropriate because fluid restriction would worsen hypernatremia in diabetes insipidus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an urgent noncontrast CT scan of the head is inappropriate because head CT is not the most appropriate next step when the presentation already strongly supports postoperative central diabetes insipidus without focal neurologic deterioration."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure a morning serum cortisol concentration is inappropriate because adrenal insufficiency does not cause hypernatremic polyuria with dilute urine after sellar surgery; it more often causes hyponatremia."
            },
            {
              "id": "B",
              "text": "Option A: Administer a bolus of 3% saline is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not hypernatremia from free-water loss."
            },
            {
              "id": "C",
              "text": "Option B: Restrict oral fluids is inappropriate because fluid restriction would worsen hypernatremia in diabetes insipidus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure a morning serum cortisol concentration is inappropriate because adrenal insufficiency does not cause hypernatremic polyuria with dilute urine after sellar surgery; it more often causes hyponatremia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Change the intravenous fluids to 0.45% saline only is inappropriate because hypotonic fluid may help replace water losses, but by itself it does not address the ADH deficiency causing ongoing high-volume dilute urine output."
            },
            {
              "id": "B",
              "text": "Option A: Administer a bolus of 3% saline is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not hypernatremia from free-water loss."
            },
            {
              "id": "C",
              "text": "Option B: Restrict oral fluids is inappropriate because fluid restriction would worsen hypernatremia in diabetes insipidus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Change the intravenous fluids to 0.45% saline only is inappropriate because hypotonic fluid may help replace water losses, but by itself it does not address the ADH deficiency causing ongoing high-volume dilute urine output."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin hydrochlorothiazide therapy is inappropriate because thiazides are used in nephrogenic diabetes insipidus, not as first-line therapy for acute postoperative central diabetes insipidus."
            },
            {
              "id": "B",
              "text": "Option A: Administer a bolus of 3% saline is inappropriate because hypertonic saline is used for severe symptomatic hyponatremia, not hypernatremia from free-water loss."
            },
            {
              "id": "C",
              "text": "Option B: Restrict oral fluids is inappropriate because fluid restriction would worsen hypernatremia in diabetes insipidus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin hydrochlorothiazide therapy is inappropriate because thiazides are used in nephrogenic diabetes insipidus, not as first-line therapy for acute postoperative central diabetes insipidus."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i042-adolescent-contraception-open-ended-counseling",
      "expectedHashes": {
        "ranaze_step3_uat": "77f55bff8be44dc2b04ba86401c0310c843168c7fb217fdf7296089acbf520bf",
        "ranaze_step3_prd": "77f55bff8be44dc2b04ba86401c0310c843168c7fb217fdf7296089acbf520bf"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022The implant is the most effective method, so we should arrange that today.\u0022 is inappropriate because jumping immediately to a specific method skips the needed discussion of her preferences, concerns, and goals."
            },
            {
              "id": "B",
              "text": "Option B: \u0022Because you are not sexually active yet, wait until after it happens and then come back for contraception.\u0022 is inappropriate because delaying counseling until after sex occurs misses an important preventive opportunity."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Before we talk about contraception, I need one of your parents to join us.\u0022 is inappropriate because confidential contraceptive counseling for an adolescent generally does not require a parent in the room."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022The implant is the most effective method, so we should arrange that today.\u0022 is inappropriate because jumping immediately to a specific method skips the needed discussion of her preferences, concerns, and goals."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Because you are not sexually active yet, wait until after it happens and then come back for contraception.\u0022 is inappropriate because delaying counseling until after sex occurs misses an important preventive opportunity."
            },
            {
              "id": "B",
              "text": "Option A: \u0022The implant is the most effective method, so we should arrange that today.\u0022 is inappropriate because jumping immediately to a specific method skips the needed discussion of her preferences, concerns, and goals."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Before we talk about contraception, I need one of your parents to join us.\u0022 is inappropriate because confidential contraceptive counseling for an adolescent generally does not require a parent in the room."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Because you are not sexually active yet, wait until after it happens and then come back for contraception.\u0022 is inappropriate because delaying counseling until after sex occurs misses an important preventive opportunity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Before we talk about contraception, I need one of your parents to join us.\u0022 is inappropriate because confidential contraceptive counseling for an adolescent generally does not require a parent in the room."
            },
            {
              "id": "B",
              "text": "Option A: \u0022The implant is the most effective method, so we should arrange that today.\u0022 is inappropriate because jumping immediately to a specific method skips the needed discussion of her preferences, concerns, and goals."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Because you are not sexually active yet, wait until after it happens and then come back for contraception.\u0022 is inappropriate because delaying counseling until after sex occurs misses an important preventive opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Before we talk about contraception, I need one of your parents to join us.\u0022 is inappropriate because confidential contraceptive counseling for an adolescent generally does not require a parent in the room."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Sex can change your life in major ways, so you should think very carefully before doing it.\u0022 is inappropriate because this response is judgmental and closes off discussion instead of inviting the patient to share her thoughts and concerns."
            },
            {
              "id": "B",
              "text": "Option A: \u0022The implant is the most effective method, so we should arrange that today.\u0022 is inappropriate because jumping immediately to a specific method skips the needed discussion of her preferences, concerns, and goals."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Because you are not sexually active yet, wait until after it happens and then come back for contraception.\u0022 is inappropriate because delaying counseling until after sex occurs misses an important preventive opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Sex can change your life in major ways, so you should think very carefully before doing it.\u0022 is inappropriate because this response is judgmental and closes off discussion instead of inviting the patient to share her thoughts and concerns."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022If avoiding pregnancy is your main concern, condoms should be enough.\u0022 is inappropriate because condoms reduce pregnancy risk and help prevent sexually transmitted infections, but they are not the most effective single method for pregnancy prevention."
            },
            {
              "id": "B",
              "text": "Option A: \u0022The implant is the most effective method, so we should arrange that today.\u0022 is inappropriate because jumping immediately to a specific method skips the needed discussion of her preferences, concerns, and goals."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Because you are not sexually active yet, wait until after it happens and then come back for contraception.\u0022 is inappropriate because delaying counseling until after sex occurs misses an important preventive opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022If avoiding pregnancy is your main concern, condoms should be enough.\u0022 is inappropriate because condoms reduce pregnancy risk and help prevent sexually transmitted infections, but they are not the most effective single method for pregnancy prevention."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022The safest choice is to avoid sex altogether until you are older.\u0022 is inappropriate because telling her simply to avoid sex is directive and not patient-centered counseling."
            },
            {
              "id": "B",
              "text": "Option A: \u0022The implant is the most effective method, so we should arrange that today.\u0022 is inappropriate because jumping immediately to a specific method skips the needed discussion of her preferences, concerns, and goals."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Because you are not sexually active yet, wait until after it happens and then come back for contraception.\u0022 is inappropriate because delaying counseling until after sex occurs misses an important preventive opportunity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022The safest choice is to avoid sex altogether until you are older.\u0022 is inappropriate because telling her simply to avoid sex is directive and not patient-centered counseling."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i048-noonan-pulmonic-stenosis",
      "expectedHashes": {
        "ranaze_step3_uat": "96c76ee7e2ebbaf41cdaaadf08986014b5196426512bf1cbf9ea0bfed41f65e7",
        "ranaze_step3_prd": "96c76ee7e2ebbaf41cdaaadf08986014b5196426512bf1cbf9ea0bfed41f65e7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aortic coarctation is inappropriate because coarctation usually causes diminished femoral pulses and a murmur best heard over the back, not a classic pulmonic-area systolic ejection murmur in a child with Noonan features."
            },
            {
              "id": "B",
              "text": "Option B: Atrioventricular septal defects are more strongly associated with trisomy 21 and usually produce murmurs from AV valve regurgitation or increased flow rather than isolated pulmonic-area ejection murmur."
            },
            {
              "id": "C",
              "text": "Option C: Bicuspid aortic valve causes an aortic outflow murmur best heard at the right upper sternal border."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aortic coarctation is inappropriate because coarctation usually causes diminished femoral pulses and a murmur best heard over the back, not a classic pulmonic-area systolic ejection murmur in a child with Noonan features."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Atrioventricular septal defects are more strongly associated with trisomy 21 and usually produce murmurs from AV valve regurgitation or increased flow rather than isolated pulmonic-area ejection murmur."
            },
            {
              "id": "B",
              "text": "Option A: Aortic coarctation is inappropriate because coarctation usually causes diminished femoral pulses and a murmur best heard over the back, not a classic pulmonic-area systolic ejection murmur in a child with Noonan features."
            },
            {
              "id": "C",
              "text": "Option C: Bicuspid aortic valve causes an aortic outflow murmur best heard at the right upper sternal border."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Atrioventricular septal defects are more strongly associated with trisomy 21 and usually produce murmurs from AV valve regurgitation or increased flow rather than isolated pulmonic-area ejection murmur."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bicuspid aortic valve causes an aortic outflow murmur best heard at the right upper sternal border."
            },
            {
              "id": "B",
              "text": "Option A: Aortic coarctation is inappropriate because coarctation usually causes diminished femoral pulses and a murmur best heard over the back, not a classic pulmonic-area systolic ejection murmur in a child with Noonan features."
            },
            {
              "id": "C",
              "text": "Option B: Atrioventricular septal defects are more strongly associated with trisomy 21 and usually produce murmurs from AV valve regurgitation or increased flow rather than isolated pulmonic-area ejection murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bicuspid aortic valve causes an aortic outflow murmur best heard at the right upper sternal border."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mitral regurgitation causes a holosystolic murmur best heard at the apex."
            },
            {
              "id": "B",
              "text": "Option A: Aortic coarctation is inappropriate because coarctation usually causes diminished femoral pulses and a murmur best heard over the back, not a classic pulmonic-area systolic ejection murmur in a child with Noonan features."
            },
            {
              "id": "C",
              "text": "Option B: Atrioventricular septal defects are more strongly associated with trisomy 21 and usually produce murmurs from AV valve regurgitation or increased flow rather than isolated pulmonic-area ejection murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mitral regurgitation causes a holosystolic murmur best heard at the apex."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patent ductus arteriosus classically causes a continuous machinery murmur."
            },
            {
              "id": "B",
              "text": "Option A: Aortic coarctation is inappropriate because coarctation usually causes diminished femoral pulses and a murmur best heard over the back, not a classic pulmonic-area systolic ejection murmur in a child with Noonan features."
            },
            {
              "id": "C",
              "text": "Option B: Atrioventricular septal defects are more strongly associated with trisomy 21 and usually produce murmurs from AV valve regurgitation or increased flow rather than isolated pulmonic-area ejection murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patent ductus arteriosus classically causes a continuous machinery murmur."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A perimembranous ventricular septal defect usually causes a harsh holosystolic murmur at the lower left sternal border."
            },
            {
              "id": "B",
              "text": "Option A: Aortic coarctation is inappropriate because coarctation usually causes diminished femoral pulses and a murmur best heard over the back, not a classic pulmonic-area systolic ejection murmur in a child with Noonan features."
            },
            {
              "id": "C",
              "text": "Option B: Atrioventricular septal defects are more strongly associated with trisomy 21 and usually produce murmurs from AV valve regurgitation or increased flow rather than isolated pulmonic-area ejection murmur."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A perimembranous ventricular septal defect usually causes a harsh holosystolic murmur at the lower left sternal border."
        }
      }
    },
    {
      "externalId": "nbme6-s2-i049-amiodarone-interstitial-lung-disease",
      "expectedHashes": {
        "ranaze_step3_uat": "07715a34177614320a22c522a562eab2dd3a594b10c9cb4c4820dbbf24cc54b8",
        "ranaze_step3_prd": "07715a34177614320a22c522a562eab2dd3a594b10c9cb4c4820dbbf24cc54b8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Normal total lung capacity with normal diffusing capacity is inappropriate because interstitial lung disease from amiodarone would not be expected to have both normal lung volumes and normal diffusing capacity."
            },
            {
              "id": "B",
              "text": "Option C: Reduced FEV1/FVC ratio with increased residual volume is inappropriate because a reduced FEV1/FVC ratio with air trapping suggests obstructive disease such as COPD or asthma."
            },
            {
              "id": "C",
              "text": "Option D: Increased total lung capacity with increased residual volume is inappropriate because increased total lung capacity and residual volume suggest hyperinflation, not interstitial fibrosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Normal total lung capacity with normal diffusing capacity is inappropriate because interstitial lung disease from amiodarone would not be expected to have both normal lung volumes and normal diffusing capacity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduced FEV1/FVC ratio with increased residual volume is inappropriate because a reduced FEV1/FVC ratio with air trapping suggests obstructive disease such as COPD or asthma."
            },
            {
              "id": "B",
              "text": "Option A: Normal total lung capacity with normal diffusing capacity is inappropriate because interstitial lung disease from amiodarone would not be expected to have both normal lung volumes and normal diffusing capacity."
            },
            {
              "id": "C",
              "text": "Option D: Increased total lung capacity with increased residual volume is inappropriate because increased total lung capacity and residual volume suggest hyperinflation, not interstitial fibrosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduced FEV1/FVC ratio with increased residual volume is inappropriate because a reduced FEV1/FVC ratio with air trapping suggests obstructive disease such as COPD or asthma."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased total lung capacity with increased residual volume is inappropriate because increased total lung capacity and residual volume suggest hyperinflation, not interstitial fibrosis."
            },
            {
              "id": "B",
              "text": "Option A: Normal total lung capacity with normal diffusing capacity is inappropriate because interstitial lung disease from amiodarone would not be expected to have both normal lung volumes and normal diffusing capacity."
            },
            {
              "id": "C",
              "text": "Option C: Reduced FEV1/FVC ratio with increased residual volume is inappropriate because a reduced FEV1/FVC ratio with air trapping suggests obstructive disease such as COPD or asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased total lung capacity with increased residual volume is inappropriate because increased total lung capacity and residual volume suggest hyperinflation, not interstitial fibrosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Normal FEV1 with isolated increase in residual volume is inappropriate because an isolated increase in residual volume points to air trapping rather than restrictive interstitial disease."
            },
            {
              "id": "B",
              "text": "Option A: Normal total lung capacity with normal diffusing capacity is inappropriate because interstitial lung disease from amiodarone would not be expected to have both normal lung volumes and normal diffusing capacity."
            },
            {
              "id": "C",
              "text": "Option C: Reduced FEV1/FVC ratio with increased residual volume is inappropriate because a reduced FEV1/FVC ratio with air trapping suggests obstructive disease such as COPD or asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Normal FEV1 with isolated increase in residual volume is inappropriate because an isolated increase in residual volume points to air trapping rather than restrictive interstitial disease."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Marked bronchodilator response after albuterol administration is inappropriate because a large bronchodilator response supports reversible bronchospasm, which does not fit this presentation."
            },
            {
              "id": "B",
              "text": "Option A: Normal total lung capacity with normal diffusing capacity is inappropriate because interstitial lung disease from amiodarone would not be expected to have both normal lung volumes and normal diffusing capacity."
            },
            {
              "id": "C",
              "text": "Option C: Reduced FEV1/FVC ratio with increased residual volume is inappropriate because a reduced FEV1/FVC ratio with air trapping suggests obstructive disease such as COPD or asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Marked bronchodilator response after albuterol administration is inappropriate because a large bronchodilator response supports reversible bronchospasm, which does not fit this presentation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Normal diffusing capacity with mildly reduced vital capacity is inappropriate because interstitial lung disease commonly lowers diffusing capacity; a normal diffusing capacity would be atypical."
            },
            {
              "id": "B",
              "text": "Option A: Normal total lung capacity with normal diffusing capacity is inappropriate because interstitial lung disease from amiodarone would not be expected to have both normal lung volumes and normal diffusing capacity."
            },
            {
              "id": "C",
              "text": "Option C: Reduced FEV1/FVC ratio with increased residual volume is inappropriate because a reduced FEV1/FVC ratio with air trapping suggests obstructive disease such as COPD or asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Normal diffusing capacity with mildly reduced vital capacity is inappropriate because interstitial lung disease commonly lowers diffusing capacity; a normal diffusing capacity would be atypical."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i003-median-neuropathy-thyroid-evaluation",
      "expectedHashes": {
        "ranaze_step3_uat": "9f5460161f8351ced42b2e2b1db660505fb933d77b663f5f15815a8b24c07e1e",
        "ranaze_step3_prd": "9f5460161f8351ced42b2e2b1db660505fb933d77b663f5f15815a8b24c07e1e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An erythrocyte sedimentation rate can support evaluation of systemic inflammation, but this presentation is a focal median neuropathy with signs of hypothyroidism."
            },
            {
              "id": "B",
              "text": "Option B: Serum uric acid concentration is inappropriate because hyperuricemia is relevant to gout, not to this nocturnal median nerve compression pattern."
            },
            {
              "id": "C",
              "text": "Option C: Cervical spine MRI is not the best initial study for isolated sensory symptoms in the median nerve distribution with clear wrist-provoked symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An erythrocyte sedimentation rate can support evaluation of systemic inflammation, but this presentation is a focal median neuropathy with signs of hypothyroidism."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum uric acid concentration is inappropriate because hyperuricemia is relevant to gout, not to this nocturnal median nerve compression pattern."
            },
            {
              "id": "B",
              "text": "Option A: An erythrocyte sedimentation rate can support evaluation of systemic inflammation, but this presentation is a focal median neuropathy with signs of hypothyroidism."
            },
            {
              "id": "C",
              "text": "Option C: Cervical spine MRI is not the best initial study for isolated sensory symptoms in the median nerve distribution with clear wrist-provoked symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum uric acid concentration is inappropriate because hyperuricemia is relevant to gout, not to this nocturnal median nerve compression pattern."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cervical spine MRI is not the best initial study for isolated sensory symptoms in the median nerve distribution with clear wrist-provoked symptoms."
            },
            {
              "id": "B",
              "text": "Option A: An erythrocyte sedimentation rate can support evaluation of systemic inflammation, but this presentation is a focal median neuropathy with signs of hypothyroidism."
            },
            {
              "id": "C",
              "text": "Option B: Serum uric acid concentration is inappropriate because hyperuricemia is relevant to gout, not to this nocturnal median nerve compression pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cervical spine MRI is not the best initial study for isolated sensory symptoms in the median nerve distribution with clear wrist-provoked symptoms."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum vitamin B12 concentration is inappropriate because vitamin B12 deficiency causes a more diffuse neuropathy or myelopathy rather than isolated numbness triggered by wrist position."
            },
            {
              "id": "B",
              "text": "Option A: An erythrocyte sedimentation rate can support evaluation of systemic inflammation, but this presentation is a focal median neuropathy with signs of hypothyroidism."
            },
            {
              "id": "C",
              "text": "Option B: Serum uric acid concentration is inappropriate because hyperuricemia is relevant to gout, not to this nocturnal median nerve compression pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum vitamin B12 concentration is inappropriate because vitamin B12 deficiency causes a more diffuse neuropathy or myelopathy rather than isolated numbness triggered by wrist position."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum growth hormone concentration is inappropriate because growth hormone excess can predispose to carpal tunnel syndrome in acromegaly, but this stem instead gives symptoms of undertreated hypothyroidism."
            },
            {
              "id": "B",
              "text": "Option A: An erythrocyte sedimentation rate can support evaluation of systemic inflammation, but this presentation is a focal median neuropathy with signs of hypothyroidism."
            },
            {
              "id": "C",
              "text": "Option B: Serum uric acid concentration is inappropriate because hyperuricemia is relevant to gout, not to this nocturnal median nerve compression pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum growth hormone concentration is inappropriate because growth hormone excess can predispose to carpal tunnel syndrome in acromegaly, but this stem instead gives symptoms of undertreated hypothyroidism."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum rheumatoid factor is inappropriate because rheumatoid factor is not the best next test in an isolated median neuropathy without inflammatory polyarthritis."
            },
            {
              "id": "B",
              "text": "Option A: An erythrocyte sedimentation rate can support evaluation of systemic inflammation, but this presentation is a focal median neuropathy with signs of hypothyroidism."
            },
            {
              "id": "C",
              "text": "Option B: Serum uric acid concentration is inappropriate because hyperuricemia is relevant to gout, not to this nocturnal median nerve compression pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum rheumatoid factor is inappropriate because rheumatoid factor is not the best next test in an isolated median neuropathy without inflammatory polyarthritis."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i007-initial-spinal-cord-compression-therapy",
      "expectedHashes": {
        "ranaze_step3_uat": "1d8cfcdd7e18f9b1d427dc8bd7595b80c9f891f431d2f3cd0ed30d5254c53786",
        "ranaze_step3_prd": "1d8cfcdd7e18f9b1d427dc8bd7595b80c9f891f431d2f3cd0ed30d5254c53786"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin meclizine therapy is inappropriate because meclizine treats vertigo, not acute malignant spinal cord compression."
            },
            {
              "id": "B",
              "text": "Option C: Administer IV mannitol is inappropriate because mannitol is used for elevated intracranial pressure, not as first-line therapy for epidural spinal cord compression."
            },
            {
              "id": "C",
              "text": "Option D: Begin broad-spectrum antibiotics is inappropriate because antibiotics would be appropriate for suspected epidural abscess, but this stem gives metastatic prostate cancer with MRI-confirmed epidural tumor compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin meclizine therapy is inappropriate because meclizine treats vertigo, not acute malignant spinal cord compression."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer IV mannitol is inappropriate because mannitol is used for elevated intracranial pressure, not as first-line therapy for epidural spinal cord compression."
            },
            {
              "id": "B",
              "text": "Option A: Begin meclizine therapy is inappropriate because meclizine treats vertigo, not acute malignant spinal cord compression."
            },
            {
              "id": "C",
              "text": "Option D: Begin broad-spectrum antibiotics is inappropriate because antibiotics would be appropriate for suspected epidural abscess, but this stem gives metastatic prostate cancer with MRI-confirmed epidural tumor compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer IV mannitol is inappropriate because mannitol is used for elevated intracranial pressure, not as first-line therapy for epidural spinal cord compression."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin broad-spectrum antibiotics is inappropriate because antibiotics would be appropriate for suspected epidural abscess, but this stem gives metastatic prostate cancer with MRI-confirmed epidural tumor compression."
            },
            {
              "id": "B",
              "text": "Option A: Begin meclizine therapy is inappropriate because meclizine treats vertigo, not acute malignant spinal cord compression."
            },
            {
              "id": "C",
              "text": "Option C: Administer IV mannitol is inappropriate because mannitol is used for elevated intracranial pressure, not as first-line therapy for epidural spinal cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin broad-spectrum antibiotics is inappropriate because antibiotics would be appropriate for suspected epidural abscess, but this stem gives metastatic prostate cancer with MRI-confirmed epidural tumor compression."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observe overnight and repeat the neurologic examination is inappropriate because observation would risk permanent neurologic loss in an oncologic emergency."
            },
            {
              "id": "B",
              "text": "Option A: Begin meclizine therapy is inappropriate because meclizine treats vertigo, not acute malignant spinal cord compression."
            },
            {
              "id": "C",
              "text": "Option C: Administer IV mannitol is inappropriate because mannitol is used for elevated intracranial pressure, not as first-line therapy for epidural spinal cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observe overnight and repeat the neurologic examination is inappropriate because observation would risk permanent neurologic loss in an oncologic emergency."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule outpatient physical therapy is inappropriate because physical therapy is not appropriate before emergent stabilization of spinal cord compression."
            },
            {
              "id": "B",
              "text": "Option A: Begin meclizine therapy is inappropriate because meclizine treats vertigo, not acute malignant spinal cord compression."
            },
            {
              "id": "C",
              "text": "Option C: Administer IV mannitol is inappropriate because mannitol is used for elevated intracranial pressure, not as first-line therapy for epidural spinal cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule outpatient physical therapy is inappropriate because physical therapy is not appropriate before emergent stabilization of spinal cord compression."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start long-term androgen-deprivation therapy only is inappropriate because systemic cancer treatment alone is too slow for an acute compressive neurologic emergency."
            },
            {
              "id": "B",
              "text": "Option A: Begin meclizine therapy is inappropriate because meclizine treats vertigo, not acute malignant spinal cord compression."
            },
            {
              "id": "C",
              "text": "Option C: Administer IV mannitol is inappropriate because mannitol is used for elevated intracranial pressure, not as first-line therapy for epidural spinal cord compression."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start long-term androgen-deprivation therapy only is inappropriate because systemic cancer treatment alone is too slow for an acute compressive neurologic emergency."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i008-older-adult-lymphocytosis-smudge-cells",
      "expectedHashes": {
        "ranaze_step3_uat": "0d4fc7ca02b57afb64d032b50e2dd09ed4377d648a4c4febb544ada21bdc29e7",
        "ranaze_step3_prd": "0d4fc7ca02b57afb64d032b50e2dd09ed4377d648a4c4febb544ada21bdc29e7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute lymphoblastic leukemia usually presents with blasts rather than mature-appearing lymphocytes and is less typical in this age group."
            },
            {
              "id": "B",
              "text": "Option C: Chronic myelogenous leukemia causes marked granulocytic proliferation, often with basophilia, rather than a smear dominated by mature lymphocytes and smudge cells."
            },
            {
              "id": "C",
              "text": "Option D: Hairy cell leukemia more often causes cytopenias and characteristic hairy B cells, not numerous smudge cells."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute lymphoblastic leukemia usually presents with blasts rather than mature-appearing lymphocytes and is less typical in this age group."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic myelogenous leukemia causes marked granulocytic proliferation, often with basophilia, rather than a smear dominated by mature lymphocytes and smudge cells."
            },
            {
              "id": "B",
              "text": "Option A: Acute lymphoblastic leukemia usually presents with blasts rather than mature-appearing lymphocytes and is less typical in this age group."
            },
            {
              "id": "C",
              "text": "Option D: Hairy cell leukemia more often causes cytopenias and characteristic hairy B cells, not numerous smudge cells."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic myelogenous leukemia causes marked granulocytic proliferation, often with basophilia, rather than a smear dominated by mature lymphocytes and smudge cells."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hairy cell leukemia more often causes cytopenias and characteristic hairy B cells, not numerous smudge cells."
            },
            {
              "id": "B",
              "text": "Option A: Acute lymphoblastic leukemia usually presents with blasts rather than mature-appearing lymphocytes and is less typical in this age group."
            },
            {
              "id": "C",
              "text": "Option C: Chronic myelogenous leukemia causes marked granulocytic proliferation, often with basophilia, rather than a smear dominated by mature lymphocytes and smudge cells."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hairy cell leukemia more often causes cytopenias and characteristic hairy B cells, not numerous smudge cells."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Multiple myeloma causes a plasma-cell dyscrasia with findings such as bone pain, renal dysfunction, hypercalcemia, or rouleaux, not isolated lymphocytosis with smudge cells."
            },
            {
              "id": "B",
              "text": "Option A: Acute lymphoblastic leukemia usually presents with blasts rather than mature-appearing lymphocytes and is less typical in this age group."
            },
            {
              "id": "C",
              "text": "Option C: Chronic myelogenous leukemia causes marked granulocytic proliferation, often with basophilia, rather than a smear dominated by mature lymphocytes and smudge cells."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Multiple myeloma causes a plasma-cell dyscrasia with findings such as bone pain, renal dysfunction, hypercalcemia, or rouleaux, not isolated lymphocytosis with smudge cells."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Myelodysplastic syndrome causes ineffective hematopoiesis and cytopenias, not a classic mature lymphocytic leukocytosis with smudge cells."
            },
            {
              "id": "B",
              "text": "Option A: Acute lymphoblastic leukemia usually presents with blasts rather than mature-appearing lymphocytes and is less typical in this age group."
            },
            {
              "id": "C",
              "text": "Option C: Chronic myelogenous leukemia causes marked granulocytic proliferation, often with basophilia, rather than a smear dominated by mature lymphocytes and smudge cells."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Myelodysplastic syndrome causes ineffective hematopoiesis and cytopenias, not a classic mature lymphocytic leukocytosis with smudge cells."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Non-Hodgkin lymphoma with marrow replacement is inappropriate because lymphoma with marrow involvement can affect the blood count, but the classic peripheral smear pattern here is most consistent with chronic lymphocytic leukemia."
            },
            {
              "id": "B",
              "text": "Option A: Acute lymphoblastic leukemia usually presents with blasts rather than mature-appearing lymphocytes and is less typical in this age group."
            },
            {
              "id": "C",
              "text": "Option C: Chronic myelogenous leukemia causes marked granulocytic proliferation, often with basophilia, rather than a smear dominated by mature lymphocytes and smudge cells."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Non-Hodgkin lymphoma with marrow replacement is inappropriate because lymphoma with marrow involvement can affect the blood count, but the classic peripheral smear pattern here is most consistent with chronic lymphocytic leukemia."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i019-capacitated-patient-refuses-further-chemotherapy",
      "expectedHashes": {
        "ranaze_step3_uat": "0298620a89ad96cec407545bde03858c7d82a48ca531fbf1924f2f979e1bd039",
        "ranaze_step3_prd": "0298620a89ad96cec407545bde03858c7d82a48ca531fbf1924f2f979e1bd039"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask hospital counsel to obtain a court order for dialysis is inappropriate because a court order is not appropriate when an adult patient has decision-making capacity and is refusing treatment after informed discussion."
            },
            {
              "id": "B",
              "text": "Option B: Ask the daughter to make the decision because the stakes are high is inappropriate because surrogates do not override the contemporaneous decision of a capacitated adult patient."
            },
            {
              "id": "C",
              "text": "Option C: Place the patient on an involuntary psychiatric hold is inappropriate because refusing burdensome treatment is not, by itself, evidence of suicidality or lack of capacity requiring involuntary psychiatric detention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask hospital counsel to obtain a court order for dialysis is inappropriate because a court order is not appropriate when an adult patient has decision-making capacity and is refusing treatment after informed discussion."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the daughter to make the decision because the stakes are high is inappropriate because surrogates do not override the contemporaneous decision of a capacitated adult patient."
            },
            {
              "id": "B",
              "text": "Option A: Ask hospital counsel to obtain a court order for dialysis is inappropriate because a court order is not appropriate when an adult patient has decision-making capacity and is refusing treatment after informed discussion."
            },
            {
              "id": "C",
              "text": "Option C: Place the patient on an involuntary psychiatric hold is inappropriate because refusing burdensome treatment is not, by itself, evidence of suicidality or lack of capacity requiring involuntary psychiatric detention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the daughter to make the decision because the stakes are high is inappropriate because surrogates do not override the contemporaneous decision of a capacitated adult patient."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place the patient on an involuntary psychiatric hold is inappropriate because refusing burdensome treatment is not, by itself, evidence of suicidality or lack of capacity requiring involuntary psychiatric detention."
            },
            {
              "id": "B",
              "text": "Option A: Ask hospital counsel to obtain a court order for dialysis is inappropriate because a court order is not appropriate when an adult patient has decision-making capacity and is refusing treatment after informed discussion."
            },
            {
              "id": "C",
              "text": "Option B: Ask the daughter to make the decision because the stakes are high is inappropriate because surrogates do not override the contemporaneous decision of a capacitated adult patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place the patient on an involuntary psychiatric hold is inappropriate because refusing burdensome treatment is not, by itself, evidence of suicidality or lack of capacity requiring involuntary psychiatric detention."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule a family meeting so relatives can persuade him to continue dialysis is inappropriate because family discussion can be supportive, but it is not the next step when the patient has already made a capacitated, informed refusal and relatives cannot overrule him."
            },
            {
              "id": "B",
              "text": "Option A: Ask hospital counsel to obtain a court order for dialysis is inappropriate because a court order is not appropriate when an adult patient has decision-making capacity and is refusing treatment after informed discussion."
            },
            {
              "id": "C",
              "text": "Option B: Ask the daughter to make the decision because the stakes are high is inappropriate because surrogates do not override the contemporaneous decision of a capacitated adult patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule a family meeting so relatives can persuade him to continue dialysis is inappropriate because family discussion can be supportive, but it is not the next step when the patient has already made a capacitated, informed refusal and relatives cannot overrule him."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tell the patient to find another nephrologist if he refuses recommended care is inappropriate because a physician should not abandon a patient for making an informed refusal; care should continue in a goal-concordant form."
            },
            {
              "id": "B",
              "text": "Option A: Ask hospital counsel to obtain a court order for dialysis is inappropriate because a court order is not appropriate when an adult patient has decision-making capacity and is refusing treatment after informed discussion."
            },
            {
              "id": "C",
              "text": "Option B: Ask the daughter to make the decision because the stakes are high is inappropriate because surrogates do not override the contemporaneous decision of a capacitated adult patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tell the patient to find another nephrologist if he refuses recommended care is inappropriate because a physician should not abandon a patient for making an informed refusal; care should continue in a goal-concordant form."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay action until the ethics committee reviews the case is inappropriate because routine ethics-committee delay is unnecessary when the ethical course is clear and capacity is intact."
            },
            {
              "id": "B",
              "text": "Option A: Ask hospital counsel to obtain a court order for dialysis is inappropriate because a court order is not appropriate when an adult patient has decision-making capacity and is refusing treatment after informed discussion."
            },
            {
              "id": "C",
              "text": "Option B: Ask the daughter to make the decision because the stakes are high is inappropriate because surrogates do not override the contemporaneous decision of a capacitated adult patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay action until the ethics committee reviews the case is inappropriate because routine ethics-committee delay is unnecessary when the ethical course is clear and capacity is intact."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i020-randomized-trial-with-nonsignificant-p-value",
      "expectedHashes": {
        "ranaze_step3_uat": "3641a21ad4419be20eb5aa5e3ec38956acf7d198ce0d7c4ce35d57b9ba971e5b",
        "ranaze_step3_prd": "3641a21ad4419be20eb5aa5e3ec38956acf7d198ce0d7c4ce35d57b9ba971e5b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The result proves the two treatments are exactly equivalent is inappropriate because a nonsignificant result does not prove exact equivalence; equivalence requires a specifically designed equivalence or noninferiority analysis."
            },
            {
              "id": "B",
              "text": "Option B: The difference is most likely explained by confounding despite randomization is inappropriate because randomization is intended to balance confounders, and nothing here points specifically to confounding as the explanation."
            },
            {
              "id": "C",
              "text": "Option D: The intervention caused a clinically important benefit that failed only because the placebo group was too small is inappropriate because the data presented do not establish a clinically important benefit, and this statement assumes a benefit not shown by the trial."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The result proves the two treatments are exactly equivalent is inappropriate because a nonsignificant result does not prove exact equivalence; equivalence requires a specifically designed equivalence or noninferiority analysis."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The difference is most likely explained by confounding despite randomization is inappropriate because randomization is intended to balance confounders, and nothing here points specifically to confounding as the explanation."
            },
            {
              "id": "B",
              "text": "Option A: The result proves the two treatments are exactly equivalent is inappropriate because a nonsignificant result does not prove exact equivalence; equivalence requires a specifically designed equivalence or noninferiority analysis."
            },
            {
              "id": "C",
              "text": "Option D: The intervention caused a clinically important benefit that failed only because the placebo group was too small is inappropriate because the data presented do not establish a clinically important benefit, and this statement assumes a benefit not shown by the trial."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The difference is most likely explained by confounding despite randomization is inappropriate because randomization is intended to balance confounders, and nothing here points specifically to confounding as the explanation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The intervention caused a clinically important benefit that failed only because the placebo group was too small is inappropriate because the data presented do not establish a clinically important benefit, and this statement assumes a benefit not shown by the trial."
            },
            {
              "id": "B",
              "text": "Option A: The result proves the two treatments are exactly equivalent is inappropriate because a nonsignificant result does not prove exact equivalence; equivalence requires a specifically designed equivalence or noninferiority analysis."
            },
            {
              "id": "C",
              "text": "Option B: The difference is most likely explained by confounding despite randomization is inappropriate because randomization is intended to balance confounders, and nothing here points specifically to confounding as the explanation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The intervention caused a clinically important benefit that failed only because the placebo group was too small is inappropriate because the data presented do not establish a clinically important benefit, and this statement assumes a benefit not shown by the trial."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The trial demonstrates a statistically significant benefit of prednisolone is inappropriate because a p-value of 0.50 is far above common significance thresholds such as 0.05, so the result is not statistically significant."
            },
            {
              "id": "B",
              "text": "Option A: The result proves the two treatments are exactly equivalent is inappropriate because a nonsignificant result does not prove exact equivalence; equivalence requires a specifically designed equivalence or noninferiority analysis."
            },
            {
              "id": "C",
              "text": "Option B: The difference is most likely explained by confounding despite randomization is inappropriate because randomization is intended to balance confounders, and nothing here points specifically to confounding as the explanation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The trial demonstrates a statistically significant benefit of prednisolone is inappropriate because a p-value of 0.50 is far above common significance thresholds such as 0.05, so the result is not statistically significant."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The trial demonstrates a type I error is inappropriate because a type I error means concluding a difference exists when it does not. This trial did not show a statistically significant difference."
            },
            {
              "id": "B",
              "text": "Option A: The result proves the two treatments are exactly equivalent is inappropriate because a nonsignificant result does not prove exact equivalence; equivalence requires a specifically designed equivalence or noninferiority analysis."
            },
            {
              "id": "C",
              "text": "Option B: The difference is most likely explained by confounding despite randomization is inappropriate because randomization is intended to balance confounders, and nothing here points specifically to confounding as the explanation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The trial demonstrates a type I error is inappropriate because a type I error means concluding a difference exists when it does not. This trial did not show a statistically significant difference."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The trial demonstrates a type II error is inappropriate because a type II error is possible in any underpowered study, but these data do not prove that a true benefit was missed; the best interpretation remains chance."
            },
            {
              "id": "B",
              "text": "Option A: The result proves the two treatments are exactly equivalent is inappropriate because a nonsignificant result does not prove exact equivalence; equivalence requires a specifically designed equivalence or noninferiority analysis."
            },
            {
              "id": "C",
              "text": "Option B: The difference is most likely explained by confounding despite randomization is inappropriate because randomization is intended to balance confounders, and nothing here points specifically to confounding as the explanation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The trial demonstrates a type II error is inappropriate because a type II error is possible in any underpowered study, but these data do not prove that a true benefit was missed; the best interpretation remains chance."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i022-autoimmune-comorbidity-celiac-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "35499c7bcf5759f7e0e4d4f43679d98b2962f186730c5867c4d71033b92e3842",
        "ranaze_step3_prd": "35499c7bcf5759f7e0e4d4f43679d98b2962f186730c5867c4d71033b92e3842"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Graves disease and chronic spontaneous urticaria is inappropriate because autoimmune thyroid disease can coexist with other autoimmune conditions, but this pair is less characteristic than celiac disease plus primary adrenal insufficiency in this clustering pattern."
            },
            {
              "id": "B",
              "text": "Option C: Pernicious anemia and primary ovarian insufficiency is inappropriate because these conditions can be autoimmune, but they are not the most characteristic paired additional risks in a patient who already has type 1 diabetes and autoimmune thyroid disease."
            },
            {
              "id": "C",
              "text": "Option D: Vitiligo and myasthenia gravis is inappropriate because vitiligo may coexist with endocrine autoimmunity, but myasthenia gravis is not part of the most characteristic paired association here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Graves disease and chronic spontaneous urticaria is inappropriate because autoimmune thyroid disease can coexist with other autoimmune conditions, but this pair is less characteristic than celiac disease plus primary adrenal insufficiency in this clustering pattern."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pernicious anemia and primary ovarian insufficiency is inappropriate because these conditions can be autoimmune, but they are not the most characteristic paired additional risks in a patient who already has type 1 diabetes and autoimmune thyroid disease."
            },
            {
              "id": "B",
              "text": "Option B: Graves disease and chronic spontaneous urticaria is inappropriate because autoimmune thyroid disease can coexist with other autoimmune conditions, but this pair is less characteristic than celiac disease plus primary adrenal insufficiency in this clustering pattern."
            },
            {
              "id": "C",
              "text": "Option D: Vitiligo and myasthenia gravis is inappropriate because vitiligo may coexist with endocrine autoimmunity, but myasthenia gravis is not part of the most characteristic paired association here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pernicious anemia and primary ovarian insufficiency is inappropriate because these conditions can be autoimmune, but they are not the most characteristic paired additional risks in a patient who already has type 1 diabetes and autoimmune thyroid disease."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vitiligo and myasthenia gravis is inappropriate because vitiligo may coexist with endocrine autoimmunity, but myasthenia gravis is not part of the most characteristic paired association here."
            },
            {
              "id": "B",
              "text": "Option B: Graves disease and chronic spontaneous urticaria is inappropriate because autoimmune thyroid disease can coexist with other autoimmune conditions, but this pair is less characteristic than celiac disease plus primary adrenal insufficiency in this clustering pattern."
            },
            {
              "id": "C",
              "text": "Option C: Pernicious anemia and primary ovarian insufficiency is inappropriate because these conditions can be autoimmune, but they are not the most characteristic paired additional risks in a patient who already has type 1 diabetes and autoimmune thyroid disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vitiligo and myasthenia gravis is inappropriate because vitiligo may coexist with endocrine autoimmunity, but myasthenia gravis is not part of the most characteristic paired association here."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Autoimmune hepatitis and primary sclerosing cholangitis is inappropriate because these hepatobiliary disorders are autoimmune but do not represent the classic next pair associated with type 1 diabetes plus autoimmune thyroid disease."
            },
            {
              "id": "B",
              "text": "Option B: Graves disease and chronic spontaneous urticaria is inappropriate because autoimmune thyroid disease can coexist with other autoimmune conditions, but this pair is less characteristic than celiac disease plus primary adrenal insufficiency in this clustering pattern."
            },
            {
              "id": "C",
              "text": "Option C: Pernicious anemia and primary ovarian insufficiency is inappropriate because these conditions can be autoimmune, but they are not the most characteristic paired additional risks in a patient who already has type 1 diabetes and autoimmune thyroid disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Autoimmune hepatitis and primary sclerosing cholangitis is inappropriate because these hepatobiliary disorders are autoimmune but do not represent the classic next pair associated with type 1 diabetes plus autoimmune thyroid disease."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No additional autoimmune disorders above baseline risk is inappropriate because patients with multiple autoimmune endocrinopathies are at increased, not baseline, risk for further autoimmune disease."
            },
            {
              "id": "B",
              "text": "Option B: Graves disease and chronic spontaneous urticaria is inappropriate because autoimmune thyroid disease can coexist with other autoimmune conditions, but this pair is less characteristic than celiac disease plus primary adrenal insufficiency in this clustering pattern."
            },
            {
              "id": "C",
              "text": "Option C: Pernicious anemia and primary ovarian insufficiency is inappropriate because these conditions can be autoimmune, but they are not the most characteristic paired additional risks in a patient who already has type 1 diabetes and autoimmune thyroid disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No additional autoimmune disorders above baseline risk is inappropriate because patients with multiple autoimmune endocrinopathies are at increased, not baseline, risk for further autoimmune disease."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Rheumatoid arthritis and Sjogren syndrome is inappropriate because these rheumatologic diseases are possible autoimmune comorbidities but are not the most characteristic pair in this setting."
            },
            {
              "id": "B",
              "text": "Option B: Graves disease and chronic spontaneous urticaria is inappropriate because autoimmune thyroid disease can coexist with other autoimmune conditions, but this pair is less characteristic than celiac disease plus primary adrenal insufficiency in this clustering pattern."
            },
            {
              "id": "C",
              "text": "Option C: Pernicious anemia and primary ovarian insufficiency is inappropriate because these conditions can be autoimmune, but they are not the most characteristic paired additional risks in a patient who already has type 1 diabetes and autoimmune thyroid disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Rheumatoid arthritis and Sjogren syndrome is inappropriate because these rheumatologic diseases are possible autoimmune comorbidities but are not the most characteristic pair in this setting."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i023-chronic-pain-cannabis-opioid-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "db244aea366d5a3c8ece7030afe37b4b1abcbbd8c284634d4cc39fcca5c5561e",
        "ranaze_step3_prd": "db244aea366d5a3c8ece7030afe37b4b1abcbbd8c284634d4cc39fcca5c5561e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Occasional bourbon use is inappropriate because light alcohol use matters in a full substance history, but this patient\u0027s occasional bourbon intake is less influential than daily cannabis use."
            },
            {
              "id": "B",
              "text": "Option B: Controlled hypertension is inappropriate because hypertension affects medication selection in some settings, but it is not the main factor driving opioid misuse risk assessment here."
            },
            {
              "id": "C",
              "text": "Option C: A family history of rheumatoid arthritis does not meaningfully guide chronic opioid prescribing for mechanical low back pain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Occasional bourbon use is inappropriate because light alcohol use matters in a full substance history, but this patient\u0027s occasional bourbon intake is less influential than daily cannabis use."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Controlled hypertension is inappropriate because hypertension affects medication selection in some settings, but it is not the main factor driving opioid misuse risk assessment here."
            },
            {
              "id": "B",
              "text": "Option A: Occasional bourbon use is inappropriate because light alcohol use matters in a full substance history, but this patient\u0027s occasional bourbon intake is less influential than daily cannabis use."
            },
            {
              "id": "C",
              "text": "Option C: A family history of rheumatoid arthritis does not meaningfully guide chronic opioid prescribing for mechanical low back pain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Controlled hypertension is inappropriate because hypertension affects medication selection in some settings, but it is not the main factor driving opioid misuse risk assessment here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A family history of rheumatoid arthritis does not meaningfully guide chronic opioid prescribing for mechanical low back pain."
            },
            {
              "id": "B",
              "text": "Option A: Occasional bourbon use is inappropriate because light alcohol use matters in a full substance history, but this patient\u0027s occasional bourbon intake is less influential than daily cannabis use."
            },
            {
              "id": "C",
              "text": "Option B: Controlled hypertension is inappropriate because hypertension affects medication selection in some settings, but it is not the main factor driving opioid misuse risk assessment here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A family history of rheumatoid arthritis does not meaningfully guide chronic opioid prescribing for mechanical low back pain."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Body mass index of 29 kg/m2 is inappropriate because overweight status can contribute to back pain, but it is not the key factor influencing opioid risk assessment in this vignette."
            },
            {
              "id": "B",
              "text": "Option A: Occasional bourbon use is inappropriate because light alcohol use matters in a full substance history, but this patient\u0027s occasional bourbon intake is less influential than daily cannabis use."
            },
            {
              "id": "C",
              "text": "Option B: Controlled hypertension is inappropriate because hypertension affects medication selection in some settings, but it is not the main factor driving opioid misuse risk assessment here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Body mass index of 29 kg/m2 is inappropriate because overweight status can contribute to back pain, but it is not the key factor influencing opioid risk assessment in this vignette."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remote traumatic onset of pain is inappropriate because the remote injury explains the pain history but does not by itself determine the safety profile of chronic opioid therapy."
            },
            {
              "id": "B",
              "text": "Option A: Occasional bourbon use is inappropriate because light alcohol use matters in a full substance history, but this patient\u0027s occasional bourbon intake is less influential than daily cannabis use."
            },
            {
              "id": "C",
              "text": "Option B: Controlled hypertension is inappropriate because hypertension affects medication selection in some settings, but it is not the main factor driving opioid misuse risk assessment here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remote traumatic onset of pain is inappropriate because the remote injury explains the pain history but does not by itself determine the safety profile of chronic opioid therapy."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Social supports can matter broadly, but living with a spouse is not the strongest factor among these options for opioid-prescribing risk assessment."
            },
            {
              "id": "B",
              "text": "Option A: Occasional bourbon use is inappropriate because light alcohol use matters in a full substance history, but this patient\u0027s occasional bourbon intake is less influential than daily cannabis use."
            },
            {
              "id": "C",
              "text": "Option B: Controlled hypertension is inappropriate because hypertension affects medication selection in some settings, but it is not the main factor driving opioid misuse risk assessment here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Social supports can matter broadly, but living with a spouse is not the strongest factor among these options for opioid-prescribing risk assessment."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i024-postpartum-hemorrhage-macrosomia-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "165f3992aead7451bb815d5ce2763eb9cbf9a22d578d9f6d4a9dbfcc4818a814",
        "ranaze_step3_prd": "165f3992aead7451bb815d5ce2763eb9cbf9a22d578d9f6d4a9dbfcc4818a814"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use of epidural anesthesia is inappropriate because epidural anesthesia is common in labor and is not the strongest risk factor for uterine atony in this case."
            },
            {
              "id": "B",
              "text": "Option C: Delivery at 40 weeks\u0027 gestation is inappropriate because delivery at term is normal and does not meaningfully increase the risk of uterine atony by itself."
            },
            {
              "id": "C",
              "text": "Option D: Maternal age of 29 years is inappropriate because maternal age 29 years is not a major risk factor for postpartum hemorrhage from uterine atony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use of epidural anesthesia is inappropriate because epidural anesthesia is common in labor and is not the strongest risk factor for uterine atony in this case."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delivery at 40 weeks\u0027 gestation is inappropriate because delivery at term is normal and does not meaningfully increase the risk of uterine atony by itself."
            },
            {
              "id": "B",
              "text": "Option A: Use of epidural anesthesia is inappropriate because epidural anesthesia is common in labor and is not the strongest risk factor for uterine atony in this case."
            },
            {
              "id": "C",
              "text": "Option D: Maternal age of 29 years is inappropriate because maternal age 29 years is not a major risk factor for postpartum hemorrhage from uterine atony."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delivery at 40 weeks\u0027 gestation is inappropriate because delivery at term is normal and does not meaningfully increase the risk of uterine atony by itself."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal age of 29 years is inappropriate because maternal age 29 years is not a major risk factor for postpartum hemorrhage from uterine atony."
            },
            {
              "id": "B",
              "text": "Option A: Use of epidural anesthesia is inappropriate because epidural anesthesia is common in labor and is not the strongest risk factor for uterine atony in this case."
            },
            {
              "id": "C",
              "text": "Option C: Delivery at 40 weeks\u0027 gestation is inappropriate because delivery at term is normal and does not meaningfully increase the risk of uterine atony by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal age of 29 years is inappropriate because maternal age 29 years is not a major risk factor for postpartum hemorrhage from uterine atony."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Having one prior vaginal delivery is not the key risk factor here; the notable feature is uterine overdistension from a very large infant."
            },
            {
              "id": "B",
              "text": "Option A: Use of epidural anesthesia is inappropriate because epidural anesthesia is common in labor and is not the strongest risk factor for uterine atony in this case."
            },
            {
              "id": "C",
              "text": "Option C: Delivery at 40 weeks\u0027 gestation is inappropriate because delivery at term is normal and does not meaningfully increase the risk of uterine atony by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Having one prior vaginal delivery is not the key risk factor here; the notable feature is uterine overdistension from a very large infant."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Second stage lasting 50 minutes is inappropriate because a second stage under 1 hour is not prolonged and is not the main risk factor in this vignette."
            },
            {
              "id": "B",
              "text": "Option A: Use of epidural anesthesia is inappropriate because epidural anesthesia is common in labor and is not the strongest risk factor for uterine atony in this case."
            },
            {
              "id": "C",
              "text": "Option C: Delivery at 40 weeks\u0027 gestation is inappropriate because delivery at term is normal and does not meaningfully increase the risk of uterine atony by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Second stage lasting 50 minutes is inappropriate because a second stage under 1 hour is not prolonged and is not the main risk factor in this vignette."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Second-degree perineal laceration is inappropriate because a second-degree laceration can bleed, but the boggy enlarged uterus points to uterine atony, and the major predisposing factor listed is macrosomia."
            },
            {
              "id": "B",
              "text": "Option A: Use of epidural anesthesia is inappropriate because epidural anesthesia is common in labor and is not the strongest risk factor for uterine atony in this case."
            },
            {
              "id": "C",
              "text": "Option C: Delivery at 40 weeks\u0027 gestation is inappropriate because delivery at term is normal and does not meaningfully increase the risk of uterine atony by itself."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Second-degree perineal laceration is inappropriate because a second-degree laceration can bleed, but the boggy enlarged uterus points to uterine atony, and the major predisposing factor listed is macrosomia."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i025-overdose-emergency-psychiatric-evaluation",
      "expectedHashes": {
        "ranaze_step3_uat": "0d5403b91989cf5498577b53843e73a4db1490af9000e88608f2ca0b0cce0cb5",
        "ranaze_step3_prd": "0d5403b91989cf5498577b53843e73a4db1490af9000e88608f2ca0b0cce0cb5"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide the requested hypnotic medication and keep the visit confidential as requested is inappropriate because confidentiality is important, but it does not override the need to assess possible self-harm after an overdose-like ingestion."
            },
            {
              "id": "B",
              "text": "Option B: Ask her to call a friend for support, then discharge her from the emergency department is inappropriate because social support can help, but discharge before psychiatric evaluation is unsafe in this setting."
            },
            {
              "id": "C",
              "text": "Option C: Report her immediately to the state licensing board before completing further evaluation is inappropriate because professional reporting may become relevant in some circumstances, but the immediate priority is medical and psychiatric safety assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide the requested hypnotic medication and keep the visit confidential as requested is inappropriate because confidentiality is important, but it does not override the need to assess possible self-harm after an overdose-like ingestion."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask her to call a friend for support, then discharge her from the emergency department is inappropriate because social support can help, but discharge before psychiatric evaluation is unsafe in this setting."
            },
            {
              "id": "B",
              "text": "Option A: Provide the requested hypnotic medication and keep the visit confidential as requested is inappropriate because confidentiality is important, but it does not override the need to assess possible self-harm after an overdose-like ingestion."
            },
            {
              "id": "C",
              "text": "Option C: Report her immediately to the state licensing board before completing further evaluation is inappropriate because professional reporting may become relevant in some circumstances, but the immediate priority is medical and psychiatric safety assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask her to call a friend for support, then discharge her from the emergency department is inappropriate because social support can help, but discharge before psychiatric evaluation is unsafe in this setting."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Report her immediately to the state licensing board before completing further evaluation is inappropriate because professional reporting may become relevant in some circumstances, but the immediate priority is medical and psychiatric safety assessment."
            },
            {
              "id": "B",
              "text": "Option A: Provide the requested hypnotic medication and keep the visit confidential as requested is inappropriate because confidentiality is important, but it does not override the need to assess possible self-harm after an overdose-like ingestion."
            },
            {
              "id": "C",
              "text": "Option B: Ask her to call a friend for support, then discharge her from the emergency department is inappropriate because social support can help, but discharge before psychiatric evaluation is unsafe in this setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Report her immediately to the state licensing board before completing further evaluation is inappropriate because professional reporting may become relevant in some circumstances, but the immediate priority is medical and psychiatric safety assessment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Explain that any pill ingestion requires automatic involuntary psychiatric hospitalization is inappropriate because involuntary hospitalization is not automatic after any pill ingestion; the patient first needs an appropriate psychiatric evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Provide the requested hypnotic medication and keep the visit confidential as requested is inappropriate because confidentiality is important, but it does not override the need to assess possible self-harm after an overdose-like ingestion."
            },
            {
              "id": "C",
              "text": "Option B: Ask her to call a friend for support, then discharge her from the emergency department is inappropriate because social support can help, but discharge before psychiatric evaluation is unsafe in this setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Explain that any pill ingestion requires automatic involuntary psychiatric hospitalization is inappropriate because involuntary hospitalization is not automatic after any pill ingestion; the patient first needs an appropriate psychiatric evaluation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe a short course of zolpidem and reassess her by phone the next day is inappropriate because prescribing a sedative after a recent opioid ingestion and before suicide-risk assessment is inappropriate."
            },
            {
              "id": "B",
              "text": "Option A: Provide the requested hypnotic medication and keep the visit confidential as requested is inappropriate because confidentiality is important, but it does not override the need to assess possible self-harm after an overdose-like ingestion."
            },
            {
              "id": "C",
              "text": "Option B: Ask her to call a friend for support, then discharge her from the emergency department is inappropriate because social support can help, but discharge before psychiatric evaluation is unsafe in this setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe a short course of zolpidem and reassess her by phone the next day is inappropriate because prescribing a sedative after a recent opioid ingestion and before suicide-risk assessment is inappropriate."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refuse her request but discharge her once she appears calmer is inappropriate because calmer affect does not eliminate risk after a potentially self-harm-related ingestion; evaluation is still required."
            },
            {
              "id": "B",
              "text": "Option A: Provide the requested hypnotic medication and keep the visit confidential as requested is inappropriate because confidentiality is important, but it does not override the need to assess possible self-harm after an overdose-like ingestion."
            },
            {
              "id": "C",
              "text": "Option B: Ask her to call a friend for support, then discharge her from the emergency department is inappropriate because social support can help, but discharge before psychiatric evaluation is unsafe in this setting."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refuse her request but discharge her once she appears calmer is inappropriate because calmer affect does not eliminate risk after a potentially self-harm-related ingestion; evaluation is still required."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i027-cancer-fatigue-exercise-first-line",
      "expectedHashes": {
        "ranaze_step3_uat": "897d17a15abd79b33d24f4835ea7319a16e64489a0c7443fad0300f92a4b79f8",
        "ranaze_step3_prd": "897d17a15abd79b33d24f4835ea7319a16e64489a0c7443fad0300f92a4b79f8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin darbepoetin alfa therapy is inappropriate because erythropoiesis-stimulating agents are not indicated for a patient with a normal hemoglobin level and no chemotherapy-induced symptomatic anemia."
            },
            {
              "id": "B",
              "text": "Option C: Refer for respiratory muscle-strengthening therapy is inappropriate because respiratory muscle training is used for ventilatory limitation or chronic pulmonary disease, which this patient does not have."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe modafinil therapy is inappropriate because psychostimulants are not first-line therapy for routine post-treatment cancer-related fatigue in an otherwise stable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin darbepoetin alfa therapy is inappropriate because erythropoiesis-stimulating agents are not indicated for a patient with a normal hemoglobin level and no chemotherapy-induced symptomatic anemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer for respiratory muscle-strengthening therapy is inappropriate because respiratory muscle training is used for ventilatory limitation or chronic pulmonary disease, which this patient does not have."
            },
            {
              "id": "B",
              "text": "Option A: Begin darbepoetin alfa therapy is inappropriate because erythropoiesis-stimulating agents are not indicated for a patient with a normal hemoglobin level and no chemotherapy-induced symptomatic anemia."
            },
            {
              "id": "C",
              "text": "Option D: Prescribe modafinil therapy is inappropriate because psychostimulants are not first-line therapy for routine post-treatment cancer-related fatigue in an otherwise stable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer for respiratory muscle-strengthening therapy is inappropriate because respiratory muscle training is used for ventilatory limitation or chronic pulmonary disease, which this patient does not have."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prescribe modafinil therapy is inappropriate because psychostimulants are not first-line therapy for routine post-treatment cancer-related fatigue in an otherwise stable patient."
            },
            {
              "id": "B",
              "text": "Option A: Begin darbepoetin alfa therapy is inappropriate because erythropoiesis-stimulating agents are not indicated for a patient with a normal hemoglobin level and no chemotherapy-induced symptomatic anemia."
            },
            {
              "id": "C",
              "text": "Option C: Refer for respiratory muscle-strengthening therapy is inappropriate because respiratory muscle training is used for ventilatory limitation or chronic pulmonary disease, which this patient does not have."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prescribe modafinil therapy is inappropriate because psychostimulants are not first-line therapy for routine post-treatment cancer-related fatigue in an otherwise stable patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain urgent CT imaging to evaluate for occult cancer recurrence is inappropriate because imaging is not the initial step when there are no focal symptoms, constitutional warning signs, or examination findings suggesting recurrence."
            },
            {
              "id": "B",
              "text": "Option A: Begin darbepoetin alfa therapy is inappropriate because erythropoiesis-stimulating agents are not indicated for a patient with a normal hemoglobin level and no chemotherapy-induced symptomatic anemia."
            },
            {
              "id": "C",
              "text": "Option C: Refer for respiratory muscle-strengthening therapy is inappropriate because respiratory muscle training is used for ventilatory limitation or chronic pulmonary disease, which this patient does not have."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain urgent CT imaging to evaluate for occult cancer recurrence is inappropriate because imaging is not the initial step when there are no focal symptoms, constitutional warning signs, or examination findings suggesting recurrence."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order overnight polysomnography is inappropriate because sleep testing is reserved for symptoms suggesting sleep-disordered breathing or another sleep disorder, which are absent here."
            },
            {
              "id": "B",
              "text": "Option A: Begin darbepoetin alfa therapy is inappropriate because erythropoiesis-stimulating agents are not indicated for a patient with a normal hemoglobin level and no chemotherapy-induced symptomatic anemia."
            },
            {
              "id": "C",
              "text": "Option C: Refer for respiratory muscle-strengthening therapy is inappropriate because respiratory muscle training is used for ventilatory limitation or chronic pulmonary disease, which this patient does not have."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order overnight polysomnography is inappropriate because sleep testing is reserved for symptoms suggesting sleep-disordered breathing or another sleep disorder, which are absent here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfuse packed red blood cells is inappropriate because red blood cell transfusion is inappropriate without clinically significant anemia or hemodynamic compromise."
            },
            {
              "id": "B",
              "text": "Option A: Begin darbepoetin alfa therapy is inappropriate because erythropoiesis-stimulating agents are not indicated for a patient with a normal hemoglobin level and no chemotherapy-induced symptomatic anemia."
            },
            {
              "id": "C",
              "text": "Option C: Refer for respiratory muscle-strengthening therapy is inappropriate because respiratory muscle training is used for ventilatory limitation or chronic pulmonary disease, which this patient does not have."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfuse packed red blood cells is inappropriate because red blood cell transfusion is inappropriate without clinically significant anemia or hemodynamic compromise."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i028-smoking-precontemplation-open-ended-counseling",
      "expectedHashes": {
        "ranaze_step3_uat": "a89f9202e099887b571932931c7bed6312f105272b9efbacde4a25110e49f9e9",
        "ranaze_step3_prd": "a89f9202e099887b571932931c7bed6312f105272b9efbacde4a25110e49f9e9"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Because smoking raises cardiovascular risk, I want to order a stress test and carotid ultrasound today.\u0022 is inappropriate because routine cardiologic testing is not the appropriate response to an asymptomatic smoker in a counseling encounter."
            },
            {
              "id": "B",
              "text": "Option B: \u0022Let\u0027s set a quit date for next week, and I can start nicotine replacement now.\u0022 is inappropriate because immediate action planning and pharmacotherapy are better suited to a patient who is ready to make a quit attempt."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Switching to electronic cigarettes is a safer first step than continuing cigarettes.\u0022 is inappropriate because recommending e-cigarettes as a cessation strategy is not supported as a first-line, evidence-based intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Because smoking raises cardiovascular risk, I want to order a stress test and carotid ultrasound today.\u0022 is inappropriate because routine cardiologic testing is not the appropriate response to an asymptomatic smoker in a counseling encounter."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Let\u0027s set a quit date for next week, and I can start nicotine replacement now.\u0022 is inappropriate because immediate action planning and pharmacotherapy are better suited to a patient who is ready to make a quit attempt."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Because smoking raises cardiovascular risk, I want to order a stress test and carotid ultrasound today.\u0022 is inappropriate because routine cardiologic testing is not the appropriate response to an asymptomatic smoker in a counseling encounter."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Switching to electronic cigarettes is a safer first step than continuing cigarettes.\u0022 is inappropriate because recommending e-cigarettes as a cessation strategy is not supported as a first-line, evidence-based intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Let\u0027s set a quit date for next week, and I can start nicotine replacement now.\u0022 is inappropriate because immediate action planning and pharmacotherapy are better suited to a patient who is ready to make a quit attempt."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Switching to electronic cigarettes is a safer first step than continuing cigarettes.\u0022 is inappropriate because recommending e-cigarettes as a cessation strategy is not supported as a first-line, evidence-based intervention."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Because smoking raises cardiovascular risk, I want to order a stress test and carotid ultrasound today.\u0022 is inappropriate because routine cardiologic testing is not the appropriate response to an asymptomatic smoker in a counseling encounter."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Let\u0027s set a quit date for next week, and I can start nicotine replacement now.\u0022 is inappropriate because immediate action planning and pharmacotherapy are better suited to a patient who is ready to make a quit attempt."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Switching to electronic cigarettes is a safer first step than continuing cigarettes.\u0022 is inappropriate because recommending e-cigarettes as a cessation strategy is not supported as a first-line, evidence-based intervention."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Most people avoid quitting because they fear weight gain. Is that why you\u0027re not ready?\u0022 is inappropriate because this statement makes an unsupported assumption about the patient\u0027s barrier rather than eliciting his perspective."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Because smoking raises cardiovascular risk, I want to order a stress test and carotid ultrasound today.\u0022 is inappropriate because routine cardiologic testing is not the appropriate response to an asymptomatic smoker in a counseling encounter."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Let\u0027s set a quit date for next week, and I can start nicotine replacement now.\u0022 is inappropriate because immediate action planning and pharmacotherapy are better suited to a patient who is ready to make a quit attempt."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Most people avoid quitting because they fear weight gain. Is that why you\u0027re not ready?\u0022 is inappropriate because this statement makes an unsupported assumption about the patient\u0027s barrier rather than eliciting his perspective."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022If you ever decide to quit, check whether your employer offers cash incentives for smoking cessation.\u0022 is inappropriate because future logistical advice is less useful than engaging the patient\u0027s beliefs and readiness in the current visit."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Because smoking raises cardiovascular risk, I want to order a stress test and carotid ultrasound today.\u0022 is inappropriate because routine cardiologic testing is not the appropriate response to an asymptomatic smoker in a counseling encounter."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Let\u0027s set a quit date for next week, and I can start nicotine replacement now.\u0022 is inappropriate because immediate action planning and pharmacotherapy are better suited to a patient who is ready to make a quit attempt."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022If you ever decide to quit, check whether your employer offers cash incentives for smoking cessation.\u0022 is inappropriate because future logistical advice is less useful than engaging the patient\u0027s beliefs and readiness in the current visit."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022You need to stop smoking now; continuing this habit is a dangerous choice.\u0022 is inappropriate because confrontational counseling is less effective than collaborative, patient-centered exploration."
            },
            {
              "id": "B",
              "text": "Option A: \u0022Because smoking raises cardiovascular risk, I want to order a stress test and carotid ultrasound today.\u0022 is inappropriate because routine cardiologic testing is not the appropriate response to an asymptomatic smoker in a counseling encounter."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Let\u0027s set a quit date for next week, and I can start nicotine replacement now.\u0022 is inappropriate because immediate action planning and pharmacotherapy are better suited to a patient who is ready to make a quit attempt."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022You need to stop smoking now; continuing this habit is a dangerous choice.\u0022 is inappropriate because confrontational counseling is less effective than collaborative, patient-centered exploration."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i029-infant-hyperchloremic-acidosis-growth-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "16d721a0f68d098fea781340a63709e3c5b2193c713fe544cd543afa3029ac74",
        "ranaze_step3_prd": "16d721a0f68d098fea781340a63709e3c5b2193c713fe544cd543afa3029ac74"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Central osmotic demyelination syndrome is inappropriate because osmotic demyelination is linked to overly rapid correction of chronic hyponatremia, not to a stable hyperchloremic metabolic acidosis in a clinically recovered infant."
            },
            {
              "id": "B",
              "text": "Option C: Progressive hepatic synthetic dysfunction is inappropriate because persistent renal tubular acidosis does not typically cause primary hepatic insufficiency or impaired hepatic synthetic function."
            },
            {
              "id": "C",
              "text": "Option D: Renal tubular acidosis can occur despite otherwise preserved glomerular function; chronic untreated disease is more classically associated with growth impairment than inevitable progressive chronic kidney failure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Central osmotic demyelination syndrome is inappropriate because osmotic demyelination is linked to overly rapid correction of chronic hyponatremia, not to a stable hyperchloremic metabolic acidosis in a clinically recovered infant."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Progressive hepatic synthetic dysfunction is inappropriate because persistent renal tubular acidosis does not typically cause primary hepatic insufficiency or impaired hepatic synthetic function."
            },
            {
              "id": "B",
              "text": "Option A: Central osmotic demyelination syndrome is inappropriate because osmotic demyelination is linked to overly rapid correction of chronic hyponatremia, not to a stable hyperchloremic metabolic acidosis in a clinically recovered infant."
            },
            {
              "id": "C",
              "text": "Option D: Renal tubular acidosis can occur despite otherwise preserved glomerular function; chronic untreated disease is more classically associated with growth impairment than inevitable progressive chronic kidney failure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Progressive hepatic synthetic dysfunction is inappropriate because persistent renal tubular acidosis does not typically cause primary hepatic insufficiency or impaired hepatic synthetic function."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Renal tubular acidosis can occur despite otherwise preserved glomerular function; chronic untreated disease is more classically associated with growth impairment than inevitable progressive chronic kidney failure."
            },
            {
              "id": "B",
              "text": "Option A: Central osmotic demyelination syndrome is inappropriate because osmotic demyelination is linked to overly rapid correction of chronic hyponatremia, not to a stable hyperchloremic metabolic acidosis in a clinically recovered infant."
            },
            {
              "id": "C",
              "text": "Option C: Progressive hepatic synthetic dysfunction is inappropriate because persistent renal tubular acidosis does not typically cause primary hepatic insufficiency or impaired hepatic synthetic function."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Renal tubular acidosis can occur despite otherwise preserved glomerular function; chronic untreated disease is more classically associated with growth impairment than inevitable progressive chronic kidney failure."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Respiratory pump failure from muscle paralysis is inappropriate because hypokalemia here is mild and improving; chronic respiratory failure from muscle paralysis is not the expected untreated consequence of this persistent acid-base disorder."
            },
            {
              "id": "B",
              "text": "Option A: Central osmotic demyelination syndrome is inappropriate because osmotic demyelination is linked to overly rapid correction of chronic hyponatremia, not to a stable hyperchloremic metabolic acidosis in a clinically recovered infant."
            },
            {
              "id": "C",
              "text": "Option C: Progressive hepatic synthetic dysfunction is inappropriate because persistent renal tubular acidosis does not typically cause primary hepatic insufficiency or impaired hepatic synthetic function."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Respiratory pump failure from muscle paralysis is inappropriate because hypokalemia here is mild and improving; chronic respiratory failure from muscle paralysis is not the expected untreated consequence of this persistent acid-base disorder."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Severe neutropenia with recurrent bacterial infection is inappropriate because this electrolyte and acid-base pattern does not suggest marrow failure or an immunodeficiency syndrome causing neutropenia."
            },
            {
              "id": "B",
              "text": "Option A: Central osmotic demyelination syndrome is inappropriate because osmotic demyelination is linked to overly rapid correction of chronic hyponatremia, not to a stable hyperchloremic metabolic acidosis in a clinically recovered infant."
            },
            {
              "id": "C",
              "text": "Option C: Progressive hepatic synthetic dysfunction is inappropriate because persistent renal tubular acidosis does not typically cause primary hepatic insufficiency or impaired hepatic synthetic function."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Severe neutropenia with recurrent bacterial infection is inappropriate because this electrolyte and acid-base pattern does not suggest marrow failure or an immunodeficiency syndrome causing neutropenia."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Symptomatic hyperthyroidism is inappropriate because hyperthyroidism does not explain the persistent hyperchloremic metabolic acidosis and is not an expected consequence of leaving it untreated."
            },
            {
              "id": "B",
              "text": "Option A: Central osmotic demyelination syndrome is inappropriate because osmotic demyelination is linked to overly rapid correction of chronic hyponatremia, not to a stable hyperchloremic metabolic acidosis in a clinically recovered infant."
            },
            {
              "id": "C",
              "text": "Option C: Progressive hepatic synthetic dysfunction is inappropriate because persistent renal tubular acidosis does not typically cause primary hepatic insufficiency or impaired hepatic synthetic function."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Symptomatic hyperthyroidism is inappropriate because hyperthyroidism does not explain the persistent hyperchloremic metabolic acidosis and is not an expected consequence of leaving it untreated."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i030-capacity-refuse-chemotherapy",
      "expectedHashes": {
        "ranaze_step3_uat": "43833164ee82830c3e3138dbfdb695c1803a6aa161e682b8d80ae46ea67aa80a",
        "ranaze_step3_prd": "43833164ee82830c3e3138dbfdb695c1803a6aa161e682b8d80ae46ea67aa80a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Place her on an involuntary psychiatric hold is inappropriate because involuntary psychiatric hospitalization requires criteria such as imminent danger or grave disability, which are not shown here."
            },
            {
              "id": "B",
              "text": "Option C: Seek a court order to continue chemotherapy over her objection is inappropriate because forced chemotherapy is inappropriate when a patient has capacity to refuse treatment."
            },
            {
              "id": "C",
              "text": "Option D: Ask her brother to make the chemotherapy decision for her is inappropriate because a surrogate is not needed when the patient herself has capacity for the specific decision at hand."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Place her on an involuntary psychiatric hold is inappropriate because involuntary psychiatric hospitalization requires criteria such as imminent danger or grave disability, which are not shown here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Seek a court order to continue chemotherapy over her objection is inappropriate because forced chemotherapy is inappropriate when a patient has capacity to refuse treatment."
            },
            {
              "id": "B",
              "text": "Option B: Place her on an involuntary psychiatric hold is inappropriate because involuntary psychiatric hospitalization requires criteria such as imminent danger or grave disability, which are not shown here."
            },
            {
              "id": "C",
              "text": "Option D: Ask her brother to make the chemotherapy decision for her is inappropriate because a surrogate is not needed when the patient herself has capacity for the specific decision at hand."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Seek a court order to continue chemotherapy over her objection is inappropriate because forced chemotherapy is inappropriate when a patient has capacity to refuse treatment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask her brother to make the chemotherapy decision for her is inappropriate because a surrogate is not needed when the patient herself has capacity for the specific decision at hand."
            },
            {
              "id": "B",
              "text": "Option B: Place her on an involuntary psychiatric hold is inappropriate because involuntary psychiatric hospitalization requires criteria such as imminent danger or grave disability, which are not shown here."
            },
            {
              "id": "C",
              "text": "Option C: Seek a court order to continue chemotherapy over her objection is inappropriate because forced chemotherapy is inappropriate when a patient has capacity to refuse treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask her brother to make the chemotherapy decision for her is inappropriate because a surrogate is not needed when the patient herself has capacity for the specific decision at hand."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Require resumption of antipsychotic medication before accepting the refusal is inappropriate because a capacitated patient cannot be compelled to accept psychiatric medication as a condition for refusing medical treatment."
            },
            {
              "id": "B",
              "text": "Option B: Place her on an involuntary psychiatric hold is inappropriate because involuntary psychiatric hospitalization requires criteria such as imminent danger or grave disability, which are not shown here."
            },
            {
              "id": "C",
              "text": "Option C: Seek a court order to continue chemotherapy over her objection is inappropriate because forced chemotherapy is inappropriate when a patient has capacity to refuse treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Require resumption of antipsychotic medication before accepting the refusal is inappropriate because a capacitated patient cannot be compelled to accept psychiatric medication as a condition for refusing medical treatment."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay discharge until a second psychiatrist declares her incapable is inappropriate because there is no indication to delay implementation of a capacitated patient\u0027s choice merely because she has a chronic psychotic disorder."
            },
            {
              "id": "B",
              "text": "Option B: Place her on an involuntary psychiatric hold is inappropriate because involuntary psychiatric hospitalization requires criteria such as imminent danger or grave disability, which are not shown here."
            },
            {
              "id": "C",
              "text": "Option C: Seek a court order to continue chemotherapy over her objection is inappropriate because forced chemotherapy is inappropriate when a patient has capacity to refuse treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay discharge until a second psychiatrist declares her incapable is inappropriate because there is no indication to delay implementation of a capacitated patient\u0027s choice merely because she has a chronic psychotic disorder."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Notify law enforcement because chronic psychosis makes home living unsafe is inappropriate because chronic psychosis without current threats, violence, or inability to care for oneself does not justify law-enforcement involvement."
            },
            {
              "id": "B",
              "text": "Option B: Place her on an involuntary psychiatric hold is inappropriate because involuntary psychiatric hospitalization requires criteria such as imminent danger or grave disability, which are not shown here."
            },
            {
              "id": "C",
              "text": "Option C: Seek a court order to continue chemotherapy over her objection is inappropriate because forced chemotherapy is inappropriate when a patient has capacity to refuse treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Notify law enforcement because chronic psychosis makes home living unsafe is inappropriate because chronic psychosis without current threats, violence, or inability to care for oneself does not justify law-enforcement involvement."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i038-post-stroke-euvolemic-hyponatremia",
      "expectedHashes": {
        "ranaze_step3_uat": "ffa6806e0e5d9b6999429b2fbb50098d2cbb7def19d09685e931f5c6b080bc06",
        "ranaze_step3_prd": "ffa6806e0e5d9b6999429b2fbb50098d2cbb7def19d09685e931f5c6b080bc06"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin oral urea therapy is inappropriate because oral urea can be used in some cases of chronic SIADH, but it is not the best initial step for a stable inpatient with mild, asymptomatic hyponatremia."
            },
            {
              "id": "B",
              "text": "Option B: Give a 100-mL bolus of 3% saline is inappropriate because hypertonic saline is reserved for severe or highly symptomatic hyponatremia, such as seizures, coma, or severe encephalopathy."
            },
            {
              "id": "C",
              "text": "Option C: Start desmopressin to prevent osmotic demyelination is inappropriate because desmopressin is used to control overly rapid sodium correction in selected patients, not to treat a stable patient whose sodium is drifting downward."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin oral urea therapy is inappropriate because oral urea can be used in some cases of chronic SIADH, but it is not the best initial step for a stable inpatient with mild, asymptomatic hyponatremia."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give a 100-mL bolus of 3% saline is inappropriate because hypertonic saline is reserved for severe or highly symptomatic hyponatremia, such as seizures, coma, or severe encephalopathy."
            },
            {
              "id": "B",
              "text": "Option A: Begin oral urea therapy is inappropriate because oral urea can be used in some cases of chronic SIADH, but it is not the best initial step for a stable inpatient with mild, asymptomatic hyponatremia."
            },
            {
              "id": "C",
              "text": "Option C: Start desmopressin to prevent osmotic demyelination is inappropriate because desmopressin is used to control overly rapid sodium correction in selected patients, not to treat a stable patient whose sodium is drifting downward."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give a 100-mL bolus of 3% saline is inappropriate because hypertonic saline is reserved for severe or highly symptomatic hyponatremia, such as seizures, coma, or severe encephalopathy."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start desmopressin to prevent osmotic demyelination is inappropriate because desmopressin is used to control overly rapid sodium correction in selected patients, not to treat a stable patient whose sodium is drifting downward."
            },
            {
              "id": "B",
              "text": "Option A: Begin oral urea therapy is inappropriate because oral urea can be used in some cases of chronic SIADH, but it is not the best initial step for a stable inpatient with mild, asymptomatic hyponatremia."
            },
            {
              "id": "C",
              "text": "Option B: Give a 100-mL bolus of 3% saline is inappropriate because hypertonic saline is reserved for severe or highly symptomatic hyponatremia, such as seizures, coma, or severe encephalopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start desmopressin to prevent osmotic demyelination is inappropriate because desmopressin is used to control overly rapid sodium correction in selected patients, not to treat a stable patient whose sodium is drifting downward."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase isotonic saline infusion is inappropriate because isotonic saline is often ineffective or can worsen hyponatremia in SIADH because the urine remains more concentrated than the infused fluid."
            },
            {
              "id": "B",
              "text": "Option A: Begin oral urea therapy is inappropriate because oral urea can be used in some cases of chronic SIADH, but it is not the best initial step for a stable inpatient with mild, asymptomatic hyponatremia."
            },
            {
              "id": "C",
              "text": "Option B: Give a 100-mL bolus of 3% saline is inappropriate because hypertonic saline is reserved for severe or highly symptomatic hyponatremia, such as seizures, coma, or severe encephalopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase isotonic saline infusion is inappropriate because isotonic saline is often ineffective or can worsen hyponatremia in SIADH because the urine remains more concentrated than the infused fluid."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start fludrocortisone is inappropriate because fludrocortisone is more relevant to mineralocorticoid deficiency or some salt-wasting states, not classic euvolemic SIADH."
            },
            {
              "id": "B",
              "text": "Option A: Begin oral urea therapy is inappropriate because oral urea can be used in some cases of chronic SIADH, but it is not the best initial step for a stable inpatient with mild, asymptomatic hyponatremia."
            },
            {
              "id": "C",
              "text": "Option B: Give a 100-mL bolus of 3% saline is inappropriate because hypertonic saline is reserved for severe or highly symptomatic hyponatremia, such as seizures, coma, or severe encephalopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start fludrocortisone is inappropriate because fludrocortisone is more relevant to mineralocorticoid deficiency or some salt-wasting states, not classic euvolemic SIADH."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Initiate urgent hemodialysis is inappropriate because hemodialysis is not indicated because renal function is normal and there is no life-threatening complication requiring dialysis."
            },
            {
              "id": "B",
              "text": "Option A: Begin oral urea therapy is inappropriate because oral urea can be used in some cases of chronic SIADH, but it is not the best initial step for a stable inpatient with mild, asymptomatic hyponatremia."
            },
            {
              "id": "C",
              "text": "Option B: Give a 100-mL bolus of 3% saline is inappropriate because hypertonic saline is reserved for severe or highly symptomatic hyponatremia, such as seizures, coma, or severe encephalopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Initiate urgent hemodialysis is inappropriate because hemodialysis is not indicated because renal function is normal and there is no life-threatening complication requiring dialysis."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i039-ruq-appendicitis-from-malrotation",
      "expectedHashes": {
        "ranaze_step3_uat": "53f8801446b9b9f243b0eda99172afd43777989975475dacf79ef5210bbb6b4f",
        "ranaze_step3_prd": "53f8801446b9b9f243b0eda99172afd43777989975475dacf79ef5210bbb6b4f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Epiploic appendages are fatty peritoneal pouches along the colon, not a blind-ending tubular structure arising from the cecum."
            },
            {
              "id": "B",
              "text": "Option C: Meckel diverticulum is an outpouching of the distal ileum, not a structure arising from the cecum."
            },
            {
              "id": "C",
              "text": "Option D: The sigmoid colon is normal on laparoscopy and is not the blind-ending inflamed structure described."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Epiploic appendages are fatty peritoneal pouches along the colon, not a blind-ending tubular structure arising from the cecum."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Meckel diverticulum is an outpouching of the distal ileum, not a structure arising from the cecum."
            },
            {
              "id": "B",
              "text": "Option B: Epiploic appendages are fatty peritoneal pouches along the colon, not a blind-ending tubular structure arising from the cecum."
            },
            {
              "id": "C",
              "text": "Option D: The sigmoid colon is normal on laparoscopy and is not the blind-ending inflamed structure described."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Meckel diverticulum is an outpouching of the distal ileum, not a structure arising from the cecum."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The sigmoid colon is normal on laparoscopy and is not the blind-ending inflamed structure described."
            },
            {
              "id": "B",
              "text": "Option B: Epiploic appendages are fatty peritoneal pouches along the colon, not a blind-ending tubular structure arising from the cecum."
            },
            {
              "id": "C",
              "text": "Option C: Meckel diverticulum is an outpouching of the distal ileum, not a structure arising from the cecum."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The sigmoid colon is normal on laparoscopy and is not the blind-ending inflamed structure described."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The terminal ileum appears normal and is not the structure identified on imaging and laparoscopy."
            },
            {
              "id": "B",
              "text": "Option B: Epiploic appendages are fatty peritoneal pouches along the colon, not a blind-ending tubular structure arising from the cecum."
            },
            {
              "id": "C",
              "text": "Option C: Meckel diverticulum is an outpouching of the distal ileum, not a structure arising from the cecum."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The terminal ileum appears normal and is not the structure identified on imaging and laparoscopy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A urachal remnant connects to the bladder dome, not the cecum."
            },
            {
              "id": "B",
              "text": "Option B: Epiploic appendages are fatty peritoneal pouches along the colon, not a blind-ending tubular structure arising from the cecum."
            },
            {
              "id": "C",
              "text": "Option C: Meckel diverticulum is an outpouching of the distal ileum, not a structure arising from the cecum."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A urachal remnant connects to the bladder dome, not the cecum."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A vitelline duct remnant is related to the ileum and umbilicus, not a cecal blind-ending tubular structure."
            },
            {
              "id": "B",
              "text": "Option B: Epiploic appendages are fatty peritoneal pouches along the colon, not a blind-ending tubular structure arising from the cecum."
            },
            {
              "id": "C",
              "text": "Option C: Meckel diverticulum is an outpouching of the distal ileum, not a structure arising from the cecum."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A vitelline duct remnant is related to the ileum and umbilicus, not a cecal blind-ending tubular structure."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i040-plain-language-biopsy-counseling",
      "expectedHashes": {
        "ranaze_step3_uat": "e5299d96a1d332da1ff69a6c23ebad6d4ec5b173c0cb27a8e3c5f04887736bf9",
        "ranaze_step3_prd": "e5299d96a1d332da1ff69a6c23ebad6d4ec5b173c0cb27a8e3c5f04887736bf9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022You have endometrial intraepithelial neoplasia, but it is not cancer.\u0022 is inappropriate because this is too jargon-heavy and is inaccurate because an office biopsy showing atypical hyperplasia/EIN does not reliably exclude concurrent endometrial carcinoma."
            },
            {
              "id": "B",
              "text": "Option C: \u0022Your biopsy proves you already have uterine cancer.\u0022 is inappropriate because atypical hyperplasia/EIN is concerning but does not by itself prove established cancer on this biopsy result alone."
            },
            {
              "id": "C",
              "text": "Option D: \u0022Your endometrium is proliferative with atypia, so we need a dilatation and curettage.\u0022 is inappropriate because this response relies on jargon and jumps directly to a procedure without first explaining the diagnosis in understandable terms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022You have endometrial intraepithelial neoplasia, but it is not cancer.\u0022 is inappropriate because this is too jargon-heavy and is inaccurate because an office biopsy showing atypical hyperplasia/EIN does not reliably exclude concurrent endometrial carcinoma."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Your biopsy proves you already have uterine cancer.\u0022 is inappropriate because atypical hyperplasia/EIN is concerning but does not by itself prove established cancer on this biopsy result alone."
            },
            {
              "id": "B",
              "text": "Option B: \u0022You have endometrial intraepithelial neoplasia, but it is not cancer.\u0022 is inappropriate because this is too jargon-heavy and is inaccurate because an office biopsy showing atypical hyperplasia/EIN does not reliably exclude concurrent endometrial carcinoma."
            },
            {
              "id": "C",
              "text": "Option D: \u0022Your endometrium is proliferative with atypia, so we need a dilatation and curettage.\u0022 is inappropriate because this response relies on jargon and jumps directly to a procedure without first explaining the diagnosis in understandable terms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Your biopsy proves you already have uterine cancer.\u0022 is inappropriate because atypical hyperplasia/EIN is concerning but does not by itself prove established cancer on this biopsy result alone."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Your endometrium is proliferative with atypia, so we need a dilatation and curettage.\u0022 is inappropriate because this response relies on jargon and jumps directly to a procedure without first explaining the diagnosis in understandable terms."
            },
            {
              "id": "B",
              "text": "Option B: \u0022You have endometrial intraepithelial neoplasia, but it is not cancer.\u0022 is inappropriate because this is too jargon-heavy and is inaccurate because an office biopsy showing atypical hyperplasia/EIN does not reliably exclude concurrent endometrial carcinoma."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Your biopsy proves you already have uterine cancer.\u0022 is inappropriate because atypical hyperplasia/EIN is concerning but does not by itself prove established cancer on this biopsy result alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Your endometrium is proliferative with atypia, so we need a dilatation and curettage.\u0022 is inappropriate because this response relies on jargon and jumps directly to a procedure without first explaining the diagnosis in understandable terms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Your bleeding is from hormone imbalance, and this result is usually harmless.\u0022 is inappropriate because this is misleadingly reassuring and does not accurately communicate the premalignant significance of atypical hyperplasia/EIN."
            },
            {
              "id": "B",
              "text": "Option B: \u0022You have endometrial intraepithelial neoplasia, but it is not cancer.\u0022 is inappropriate because this is too jargon-heavy and is inaccurate because an office biopsy showing atypical hyperplasia/EIN does not reliably exclude concurrent endometrial carcinoma."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Your biopsy proves you already have uterine cancer.\u0022 is inappropriate because atypical hyperplasia/EIN is concerning but does not by itself prove established cancer on this biopsy result alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Your bleeding is from hormone imbalance, and this result is usually harmless.\u0022 is inappropriate because this is misleadingly reassuring and does not accurately communicate the premalignant significance of atypical hyperplasia/EIN."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022The lining is thickened, and there is exactly a 25% chance that cancer is present right now.\u0022 is inappropriate because quoting a precise percentage is not the best way to communicate with a patient requesting simple language, and it overstates certainty about an individual patient\u0027s concurrent cancer risk."
            },
            {
              "id": "B",
              "text": "Option B: \u0022You have endometrial intraepithelial neoplasia, but it is not cancer.\u0022 is inappropriate because this is too jargon-heavy and is inaccurate because an office biopsy showing atypical hyperplasia/EIN does not reliably exclude concurrent endometrial carcinoma."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Your biopsy proves you already have uterine cancer.\u0022 is inappropriate because atypical hyperplasia/EIN is concerning but does not by itself prove established cancer on this biopsy result alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022The lining is thickened, and there is exactly a 25% chance that cancer is present right now.\u0022 is inappropriate because quoting a precise percentage is not the best way to communicate with a patient requesting simple language, and it overstates certainty about an individual patient\u0027s concurrent cancer risk."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022The main thing to know is that we should schedule surgery; the biopsy details are too technical to discuss now.\u0022 is inappropriate because withholding an understandable explanation is poor communication; the physician should explain the result plainly before discussing next steps."
            },
            {
              "id": "B",
              "text": "Option B: \u0022You have endometrial intraepithelial neoplasia, but it is not cancer.\u0022 is inappropriate because this is too jargon-heavy and is inaccurate because an office biopsy showing atypical hyperplasia/EIN does not reliably exclude concurrent endometrial carcinoma."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Your biopsy proves you already have uterine cancer.\u0022 is inappropriate because atypical hyperplasia/EIN is concerning but does not by itself prove established cancer on this biopsy result alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022The main thing to know is that we should schedule surgery; the biopsy details are too technical to discuss now.\u0022 is inappropriate because withholding an understandable explanation is poor communication; the physician should explain the result plainly before discussing next steps."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i041-capacity-after-delirium-improves",
      "expectedHashes": {
        "ranaze_step3_uat": "fe968b80ecca448980c269330c257fd06c68718b73363c488e3916a7f1c9a000",
        "ranaze_step3_prd": "fe968b80ecca448980c269330c257fd06c68718b73363c488e3916a7f1c9a000"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "How well her chronic hypertension was controlled before admission is inappropriate because baseline control of chronic disease does not determine whether a patient with acute delirium currently has decision-making capacity."
            },
            {
              "id": "B",
              "text": "Option C: Whether her anxiety about hospitals reflects depressed mood is inappropriate because mood symptoms can coexist with impaired capacity, but tearfulness or anxiety alone does not answer the key question in a patient recovering from delirium."
            },
            {
              "id": "C",
              "text": "Option D: Whether her son can provide reliable help at home is inappropriate because home support matters for discharge planning, not for the core determination of whether the patient herself currently has capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "How well her chronic hypertension was controlled before admission is inappropriate because baseline control of chronic disease does not determine whether a patient with acute delirium currently has decision-making capacity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether her anxiety about hospitals reflects depressed mood is inappropriate because mood symptoms can coexist with impaired capacity, but tearfulness or anxiety alone does not answer the key question in a patient recovering from delirium."
            },
            {
              "id": "B",
              "text": "Option B: How well her chronic hypertension was controlled before admission is inappropriate because baseline control of chronic disease does not determine whether a patient with acute delirium currently has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option D: Whether her son can provide reliable help at home is inappropriate because home support matters for discharge planning, not for the core determination of whether the patient herself currently has capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether her anxiety about hospitals reflects depressed mood is inappropriate because mood symptoms can coexist with impaired capacity, but tearfulness or anxiety alone does not answer the key question in a patient recovering from delirium."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether her son can provide reliable help at home is inappropriate because home support matters for discharge planning, not for the core determination of whether the patient herself currently has capacity."
            },
            {
              "id": "B",
              "text": "Option B: How well her chronic hypertension was controlled before admission is inappropriate because baseline control of chronic disease does not determine whether a patient with acute delirium currently has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Whether her anxiety about hospitals reflects depressed mood is inappropriate because mood symptoms can coexist with impaired capacity, but tearfulness or anxiety alone does not answer the key question in a patient recovering from delirium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether her son can provide reliable help at home is inappropriate because home support matters for discharge planning, not for the core determination of whether the patient herself currently has capacity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether she can repeat the team\u0027s recommendation word for word is inappropriate because simple repetition is not the key historical factor and does not by itself establish understanding, appreciation, or reasoning."
            },
            {
              "id": "B",
              "text": "Option B: How well her chronic hypertension was controlled before admission is inappropriate because baseline control of chronic disease does not determine whether a patient with acute delirium currently has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Whether her anxiety about hospitals reflects depressed mood is inappropriate because mood symptoms can coexist with impaired capacity, but tearfulness or anxiety alone does not answer the key question in a patient recovering from delirium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether she can repeat the team\u0027s recommendation word for word is inappropriate because simple repetition is not the key historical factor and does not by itself establish understanding, appreciation, or reasoning."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether she completed an advance directive years ago is inappropriate because an advance directive may guide care when a patient lacks capacity, but it does not answer whether she currently has capacity during improving delirium."
            },
            {
              "id": "B",
              "text": "Option B: How well her chronic hypertension was controlled before admission is inappropriate because baseline control of chronic disease does not determine whether a patient with acute delirium currently has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Whether her anxiety about hospitals reflects depressed mood is inappropriate because mood symptoms can coexist with impaired capacity, but tearfulness or anxiety alone does not answer the key question in a patient recovering from delirium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether she completed an advance directive years ago is inappropriate because an advance directive may guide care when a patient lacks capacity, but it does not answer whether she currently has capacity during improving delirium."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether she had any falls during the month before admission is inappropriate because recent falls may affect safety planning, but they are not central to assessing decision-making capacity in this context."
            },
            {
              "id": "B",
              "text": "Option B: How well her chronic hypertension was controlled before admission is inappropriate because baseline control of chronic disease does not determine whether a patient with acute delirium currently has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Whether her anxiety about hospitals reflects depressed mood is inappropriate because mood symptoms can coexist with impaired capacity, but tearfulness or anxiety alone does not answer the key question in a patient recovering from delirium."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether she had any falls during the month before admission is inappropriate because recent falls may affect safety planning, but they are not central to assessing decision-making capacity in this context."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i042-mdro-contact-precautions",
      "expectedHashes": {
        "ranaze_step3_uat": "862b9b31b479aaa17395ebfab1c54d45eb4335da93e7b428bb5dd85319599bfa",
        "ranaze_step3_prd": "862b9b31b479aaa17395ebfab1c54d45eb4335da93e7b428bb5dd85319599bfa"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Airborne precautions are used for pathogens spread via small aerosolized particles, such as tuberculosis, measles, or varicella, not for multidrug-resistant Klebsiella bacteremia from a urinary source."
            },
            {
              "id": "B",
              "text": "Option B: Airborne plus contact precautions is inappropriate because there is no indication for airborne precautions here; the relevant added measure for this multidrug-resistant organism is contact precautions."
            },
            {
              "id": "C",
              "text": "Option D: Droplet precautions are used for organisms transmitted by large respiratory droplets; this patient has a urinary source infection with no respiratory syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Airborne precautions are used for pathogens spread via small aerosolized particles, such as tuberculosis, measles, or varicella, not for multidrug-resistant Klebsiella bacteremia from a urinary source."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Airborne plus contact precautions is inappropriate because there is no indication for airborne precautions here; the relevant added measure for this multidrug-resistant organism is contact precautions."
            },
            {
              "id": "B",
              "text": "Option A: Airborne precautions are used for pathogens spread via small aerosolized particles, such as tuberculosis, measles, or varicella, not for multidrug-resistant Klebsiella bacteremia from a urinary source."
            },
            {
              "id": "C",
              "text": "Option D: Droplet precautions are used for organisms transmitted by large respiratory droplets; this patient has a urinary source infection with no respiratory syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Airborne plus contact precautions is inappropriate because there is no indication for airborne precautions here; the relevant added measure for this multidrug-resistant organism is contact precautions."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Droplet precautions are used for organisms transmitted by large respiratory droplets; this patient has a urinary source infection with no respiratory syndrome."
            },
            {
              "id": "B",
              "text": "Option A: Airborne precautions are used for pathogens spread via small aerosolized particles, such as tuberculosis, measles, or varicella, not for multidrug-resistant Klebsiella bacteremia from a urinary source."
            },
            {
              "id": "C",
              "text": "Option B: Airborne plus contact precautions is inappropriate because there is no indication for airborne precautions here; the relevant added measure for this multidrug-resistant organism is contact precautions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Droplet precautions are used for organisms transmitted by large respiratory droplets; this patient has a urinary source infection with no respiratory syndrome."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Droplet plus contact precautions is inappropriate because contact precautions are appropriate, but adding droplet precautions is unnecessary because there is no droplet-spread process described."
            },
            {
              "id": "B",
              "text": "Option A: Airborne precautions are used for pathogens spread via small aerosolized particles, such as tuberculosis, measles, or varicella, not for multidrug-resistant Klebsiella bacteremia from a urinary source."
            },
            {
              "id": "C",
              "text": "Option B: Airborne plus contact precautions is inappropriate because there is no indication for airborne precautions here; the relevant added measure for this multidrug-resistant organism is contact precautions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Droplet plus contact precautions is inappropriate because contact precautions are appropriate, but adding droplet precautions is unnecessary because there is no droplet-spread process described."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neutropenic protective isolation is inappropriate because protective isolation is used to protect severely immunocompromised patients from outside pathogens, not to prevent spread from this patient to others."
            },
            {
              "id": "B",
              "text": "Option A: Airborne precautions are used for pathogens spread via small aerosolized particles, such as tuberculosis, measles, or varicella, not for multidrug-resistant Klebsiella bacteremia from a urinary source."
            },
            {
              "id": "C",
              "text": "Option B: Airborne plus contact precautions is inappropriate because there is no indication for airborne precautions here; the relevant added measure for this multidrug-resistant organism is contact precautions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neutropenic protective isolation is inappropriate because protective isolation is used to protect severely immunocompromised patients from outside pathogens, not to prevent spread from this patient to others."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No additional precautions are needed is inappropriate because once a multidrug-resistant organism is identified in a hospitalized patient, additional contact precautions are appropriate beyond standard precautions."
            },
            {
              "id": "B",
              "text": "Option A: Airborne precautions are used for pathogens spread via small aerosolized particles, such as tuberculosis, measles, or varicella, not for multidrug-resistant Klebsiella bacteremia from a urinary source."
            },
            {
              "id": "C",
              "text": "Option B: Airborne plus contact precautions is inappropriate because there is no indication for airborne precautions here; the relevant added measure for this multidrug-resistant organism is contact precautions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No additional precautions are needed is inappropriate because once a multidrug-resistant organism is identified in a hospitalized patient, additional contact precautions are appropriate beyond standard precautions."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i043-lytic-lesion-hematuria-staging",
      "expectedHashes": {
        "ranaze_step3_uat": "6722940b554ee511dd1b9270baf5c325b14f7eefc0e79c6da76c2156a5e327c8",
        "ranaze_step3_prd": "6722940b554ee511dd1b9270baf5c325b14f7eefc0e79c6da76c2156a5e327c8"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT scan of the chest with IV contrast is inappropriate because chest imaging may be part of later staging, but the more urgent and likely primary source is below the diaphragm."
            },
            {
              "id": "B",
              "text": "Option C: External-beam radiation therapy to the humeral lesion is inappropriate because local radiation may eventually be useful for palliation, but the primary malignancy should first be identified and staged."
            },
            {
              "id": "C",
              "text": "Option D: Immediate internal fixation of the humerus is inappropriate because immediate fixation is not the next best step because there is no displaced fracture and the patient first needs diagnostic staging of the likely primary cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT scan of the chest with IV contrast is inappropriate because chest imaging may be part of later staging, but the more urgent and likely primary source is below the diaphragm."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "External-beam radiation therapy to the humeral lesion is inappropriate because local radiation may eventually be useful for palliation, but the primary malignancy should first be identified and staged."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest with IV contrast is inappropriate because chest imaging may be part of later staging, but the more urgent and likely primary source is below the diaphragm."
            },
            {
              "id": "C",
              "text": "Option D: Immediate internal fixation of the humerus is inappropriate because immediate fixation is not the next best step because there is no displaced fracture and the patient first needs diagnostic staging of the likely primary cancer."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "External-beam radiation therapy to the humeral lesion is inappropriate because local radiation may eventually be useful for palliation, but the primary malignancy should first be identified and staged."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate internal fixation of the humerus is inappropriate because immediate fixation is not the next best step because there is no displaced fracture and the patient first needs diagnostic staging of the likely primary cancer."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest with IV contrast is inappropriate because chest imaging may be part of later staging, but the more urgent and likely primary source is below the diaphragm."
            },
            {
              "id": "C",
              "text": "Option C: External-beam radiation therapy to the humeral lesion is inappropriate because local radiation may eventually be useful for palliation, but the primary malignancy should first be identified and staged."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate internal fixation of the humerus is inappropriate because immediate fixation is not the next best step because there is no displaced fracture and the patient first needs diagnostic staging of the likely primary cancer."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Image-guided core biopsy of the humeral lesion is inappropriate because biopsy can be considered when the primary is unclear, but this vignette strongly points to a renal primary that should be characterized first with appropriate imaging."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest with IV contrast is inappropriate because chest imaging may be part of later staging, but the more urgent and likely primary source is below the diaphragm."
            },
            {
              "id": "C",
              "text": "Option C: External-beam radiation therapy to the humeral lesion is inappropriate because local radiation may eventually be useful for palliation, but the primary malignancy should first be identified and staged."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Image-guided core biopsy of the humeral lesion is inappropriate because biopsy can be considered when the primary is unclear, but this vignette strongly points to a renal primary that should be characterized first with appropriate imaging."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cystoscopy evaluates lower urinary tract pathology; the findings here point instead to a renal cortical malignancy."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest with IV contrast is inappropriate because chest imaging may be part of later staging, but the more urgent and likely primary source is below the diaphragm."
            },
            {
              "id": "C",
              "text": "Option C: External-beam radiation therapy to the humeral lesion is inappropriate because local radiation may eventually be useful for palliation, but the primary malignancy should first be identified and staged."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cystoscopy evaluates lower urinary tract pathology; the findings here point instead to a renal cortical malignancy."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum and urine protein electrophoresis is inappropriate because myeloma can cause lytic lesions, but the combination of persistent left varicocele, renal mass effect, erythrocytosis, and hypercalcemia much more strongly suggests renal cell carcinoma."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest with IV contrast is inappropriate because chest imaging may be part of later staging, but the more urgent and likely primary source is below the diaphragm."
            },
            {
              "id": "C",
              "text": "Option C: External-beam radiation therapy to the humeral lesion is inappropriate because local radiation may eventually be useful for palliation, but the primary malignancy should first be identified and staged."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum and urine protein electrophoresis is inappropriate because myeloma can cause lytic lesions, but the combination of persistent left varicocele, renal mass effect, erythrocytosis, and hypercalcemia much more strongly suggests renal cell carcinoma."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i044-medication-error-fishbone-analysis",
      "expectedHashes": {
        "ranaze_step3_uat": "306a8da0512a4b7e3e98b538cb7b4a0ce748d3164c1eba4ed4c2f02ec717b829",
        "ranaze_step3_prd": "306a8da0512a4b7e3e98b538cb7b4a0ce748d3164c1eba4ed4c2f02ec717b829"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A control chart monitors process performance and special-cause variation over time; it is not the best first tool to categorize causes of a single event."
            },
            {
              "id": "B",
              "text": "Option C: A Gantt chart is used for project scheduling and task timelines, not root-cause analysis of why an error occurred."
            },
            {
              "id": "C",
              "text": "Option D: A Pareto chart ranks the most frequent sources of recurring problems but does not organize causal categories as directly as a fishbone diagram."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A control chart monitors process performance and special-cause variation over time; it is not the best first tool to categorize causes of a single event."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A Gantt chart is used for project scheduling and task timelines, not root-cause analysis of why an error occurred."
            },
            {
              "id": "B",
              "text": "Option A: A control chart monitors process performance and special-cause variation over time; it is not the best first tool to categorize causes of a single event."
            },
            {
              "id": "C",
              "text": "Option D: A Pareto chart ranks the most frequent sources of recurring problems but does not organize causal categories as directly as a fishbone diagram."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A Gantt chart is used for project scheduling and task timelines, not root-cause analysis of why an error occurred."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A Pareto chart ranks the most frequent sources of recurring problems but does not organize causal categories as directly as a fishbone diagram."
            },
            {
              "id": "B",
              "text": "Option A: A control chart monitors process performance and special-cause variation over time; it is not the best first tool to categorize causes of a single event."
            },
            {
              "id": "C",
              "text": "Option C: A Gantt chart is used for project scheduling and task timelines, not root-cause analysis of why an error occurred."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A Pareto chart ranks the most frequent sources of recurring problems but does not organize causal categories as directly as a fishbone diagram."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A run chart displays measurements over time and is useful for monitoring change, not for initial root-cause categorization of one event."
            },
            {
              "id": "B",
              "text": "Option A: A control chart monitors process performance and special-cause variation over time; it is not the best first tool to categorize causes of a single event."
            },
            {
              "id": "C",
              "text": "Option C: A Gantt chart is used for project scheduling and task timelines, not root-cause analysis of why an error occurred."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A run chart displays measurements over time and is useful for monitoring change, not for initial root-cause categorization of one event."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A swim lane diagram maps workflow steps and role ownership; it is less suitable than a fishbone diagram when the primary goal is broad causal analysis across multiple domains."
            },
            {
              "id": "B",
              "text": "Option A: A control chart monitors process performance and special-cause variation over time; it is not the best first tool to categorize causes of a single event."
            },
            {
              "id": "C",
              "text": "Option C: A Gantt chart is used for project scheduling and task timelines, not root-cause analysis of why an error occurred."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A swim lane diagram maps workflow steps and role ownership; it is less suitable than a fishbone diagram when the primary goal is broad causal analysis across multiple domains."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A weighted decision matrix compares competing options against criteria; it is not an event-analysis tool for identifying causes."
            },
            {
              "id": "B",
              "text": "Option A: A control chart monitors process performance and special-cause variation over time; it is not the best first tool to categorize causes of a single event."
            },
            {
              "id": "C",
              "text": "Option C: A Gantt chart is used for project scheduling and task timelines, not root-cause analysis of why an error occurred."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A weighted decision matrix compares competing options against criteria; it is not an event-analysis tool for identifying causes."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i045-neonatal-jaundice-cephalohematoma-risk",
      "expectedHashes": {
        "ranaze_step3_uat": "8c442428bf58217fbfaf6f5d06016221c5963955b6bd3a2cc432381dcbdc8b9e",
        "ranaze_step3_prd": "8c442428bf58217fbfaf6f5d06016221c5963955b6bd3a2cc432381dcbdc8b9e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Birth at 39 weeks\u0027 gestation is inappropriate because thirty-nine weeks is term gestation and is not the main reason for this degree of early jaundice."
            },
            {
              "id": "B",
              "text": "Option B: Feeding every 2 to 3 hours suggests adequate intake and does not explain the jaundice as well as blood breakdown from a cephalohematoma."
            },
            {
              "id": "C",
              "text": "Option C: Male sex is not the major risk factor in this vignette."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Birth at 39 weeks\u0027 gestation is inappropriate because thirty-nine weeks is term gestation and is not the main reason for this degree of early jaundice."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Feeding every 2 to 3 hours suggests adequate intake and does not explain the jaundice as well as blood breakdown from a cephalohematoma."
            },
            {
              "id": "B",
              "text": "Option A: Birth at 39 weeks\u0027 gestation is inappropriate because thirty-nine weeks is term gestation and is not the main reason for this degree of early jaundice."
            },
            {
              "id": "C",
              "text": "Option C: Male sex is not the major risk factor in this vignette."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Feeding every 2 to 3 hours suggests adequate intake and does not explain the jaundice as well as blood breakdown from a cephalohematoma."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Male sex is not the major risk factor in this vignette."
            },
            {
              "id": "B",
              "text": "Option A: Birth at 39 weeks\u0027 gestation is inappropriate because thirty-nine weeks is term gestation and is not the main reason for this degree of early jaundice."
            },
            {
              "id": "C",
              "text": "Option B: Feeding every 2 to 3 hours suggests adequate intake and does not explain the jaundice as well as blood breakdown from a cephalohematoma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Male sex is not the major risk factor in this vignette."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal and infant blood type A positive with a negative direct antiglobulin test is inappropriate because the matching maternal and infant blood types and negative direct antiglobulin test argue against immune hemolysis as the cause."
            },
            {
              "id": "B",
              "text": "Option A: Birth at 39 weeks\u0027 gestation is inappropriate because thirty-nine weeks is term gestation and is not the main reason for this degree of early jaundice."
            },
            {
              "id": "C",
              "text": "Option B: Feeding every 2 to 3 hours suggests adequate intake and does not explain the jaundice as well as blood breakdown from a cephalohematoma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal and infant blood type A positive with a negative direct antiglobulin test is inappropriate because the matching maternal and infant blood types and negative direct antiglobulin test argue against immune hemolysis as the cause."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vacuum-assisted vaginal delivery is inappropriate because vacuum assistance is associated with scalp trauma, but the actual bilirubin-generating lesion is the cephalohematoma itself."
            },
            {
              "id": "B",
              "text": "Option A: Birth at 39 weeks\u0027 gestation is inappropriate because thirty-nine weeks is term gestation and is not the main reason for this degree of early jaundice."
            },
            {
              "id": "C",
              "text": "Option B: Feeding every 2 to 3 hours suggests adequate intake and does not explain the jaundice as well as blood breakdown from a cephalohematoma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vacuum-assisted vaginal delivery is inappropriate because vacuum assistance is associated with scalp trauma, but the actual bilirubin-generating lesion is the cephalohematoma itself."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Loss of 2% of birth weight is inappropriate because a 2% weight loss is minimal and does not suggest dehydration or poor intake as the main driver."
            },
            {
              "id": "B",
              "text": "Option A: Birth at 39 weeks\u0027 gestation is inappropriate because thirty-nine weeks is term gestation and is not the main reason for this degree of early jaundice."
            },
            {
              "id": "C",
              "text": "Option B: Feeding every 2 to 3 hours suggests adequate intake and does not explain the jaundice as well as blood breakdown from a cephalohematoma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Loss of 2% of birth weight is inappropriate because a 2% weight loss is minimal and does not suggest dehydration or poor intake as the main driver."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i046-suspected-pulmonary-embolism-anticoagulation",
      "expectedHashes": {
        "ranaze_step3_uat": "32e5261249163d15ce10fd2855c454c57730e1f554f2870ff8e16d535df63cad",
        "ranaze_step3_prd": "32e5261249163d15ce10fd2855c454c57730e1f554f2870ff8e16d535df63cad"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inhaled albuterol is inappropriate because albuterol is used for bronchospasm; the stem gives clear lungs and no wheezing."
            },
            {
              "id": "B",
              "text": "Option B: Aspirin treats platelet-mediated arterial thrombosis, not suspected venous thromboembolism causing pulmonary embolism."
            },
            {
              "id": "C",
              "text": "Option C: Clopidogrel is not appropriate initial therapy for suspected pulmonary embolism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inhaled albuterol is inappropriate because albuterol is used for bronchospasm; the stem gives clear lungs and no wheezing."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspirin treats platelet-mediated arterial thrombosis, not suspected venous thromboembolism causing pulmonary embolism."
            },
            {
              "id": "B",
              "text": "Option A: Inhaled albuterol is inappropriate because albuterol is used for bronchospasm; the stem gives clear lungs and no wheezing."
            },
            {
              "id": "C",
              "text": "Option C: Clopidogrel is not appropriate initial therapy for suspected pulmonary embolism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspirin treats platelet-mediated arterial thrombosis, not suspected venous thromboembolism causing pulmonary embolism."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Clopidogrel is not appropriate initial therapy for suspected pulmonary embolism."
            },
            {
              "id": "B",
              "text": "Option A: Inhaled albuterol is inappropriate because albuterol is used for bronchospasm; the stem gives clear lungs and no wheezing."
            },
            {
              "id": "C",
              "text": "Option B: Aspirin treats platelet-mediated arterial thrombosis, not suspected venous thromboembolism causing pulmonary embolism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Clopidogrel is not appropriate initial therapy for suspected pulmonary embolism."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous furosemide is inappropriate because furosemide is used for cardiogenic volume overload; the stem shows no pulmonary edema or heart failure syndrome."
            },
            {
              "id": "B",
              "text": "Option A: Inhaled albuterol is inappropriate because albuterol is used for bronchospasm; the stem gives clear lungs and no wheezing."
            },
            {
              "id": "C",
              "text": "Option B: Aspirin treats platelet-mediated arterial thrombosis, not suspected venous thromboembolism causing pulmonary embolism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous furosemide is inappropriate because furosemide is used for cardiogenic volume overload; the stem shows no pulmonary edema or heart failure syndrome."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous alteplase is inappropriate because systemic thrombolysis is reserved for pulmonary embolism with hemodynamic instability, shock, or other high-risk features; this patient is stable."
            },
            {
              "id": "B",
              "text": "Option A: Inhaled albuterol is inappropriate because albuterol is used for bronchospasm; the stem gives clear lungs and no wheezing."
            },
            {
              "id": "C",
              "text": "Option B: Aspirin treats platelet-mediated arterial thrombosis, not suspected venous thromboembolism causing pulmonary embolism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous alteplase is inappropriate because systemic thrombolysis is reserved for pulmonary embolism with hemodynamic instability, shock, or other high-risk features; this patient is stable."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Warfarin has delayed onset and should not be used alone as the immediate initial treatment for acute pulmonary embolism."
            },
            {
              "id": "B",
              "text": "Option A: Inhaled albuterol is inappropriate because albuterol is used for bronchospasm; the stem gives clear lungs and no wheezing."
            },
            {
              "id": "C",
              "text": "Option B: Aspirin treats platelet-mediated arterial thrombosis, not suspected venous thromboembolism causing pulmonary embolism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Warfarin has delayed onset and should not be used alone as the immediate initial treatment for acute pulmonary embolism."
        }
      }
    },
    {
      "externalId": "nbme6-s3-i050-arm-leg-pressure-gradient",
      "expectedHashes": {
        "ranaze_step3_uat": "db775ed1614f9382c4e99208ecae653d43aa0995eefd851b3b5b597daf06d896",
        "ranaze_step3_prd": "db775ed1614f9382c4e99208ecae653d43aa0995eefd851b3b5b597daf06d896"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Abdominal bruit lateral to the umbilicus is inappropriate because an abdominal bruit would point more toward renovascular hypertension, which does not explain delayed femoral pulses with a large arm-thigh pressure gradient."
            },
            {
              "id": "B",
              "text": "Option C: Continuous machinery murmur at the left infraclavicular area is inappropriate because a continuous machinery murmur suggests patent ductus arteriosus rather than the discrete obstructive lesion suggested by this pressure gradient and delayed femoral pulses."
            },
            {
              "id": "C",
              "text": "Option D: Fixed splitting of S2 suggests an atrial septal defect, not an obstructive lesion causing upper-lower extremity pressure dissociation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Abdominal bruit lateral to the umbilicus is inappropriate because an abdominal bruit would point more toward renovascular hypertension, which does not explain delayed femoral pulses with a large arm-thigh pressure gradient."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continuous machinery murmur at the left infraclavicular area is inappropriate because a continuous machinery murmur suggests patent ductus arteriosus rather than the discrete obstructive lesion suggested by this pressure gradient and delayed femoral pulses."
            },
            {
              "id": "B",
              "text": "Option A: Abdominal bruit lateral to the umbilicus is inappropriate because an abdominal bruit would point more toward renovascular hypertension, which does not explain delayed femoral pulses with a large arm-thigh pressure gradient."
            },
            {
              "id": "C",
              "text": "Option D: Fixed splitting of S2 suggests an atrial septal defect, not an obstructive lesion causing upper-lower extremity pressure dissociation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continuous machinery murmur at the left infraclavicular area is inappropriate because a continuous machinery murmur suggests patent ductus arteriosus rather than the discrete obstructive lesion suggested by this pressure gradient and delayed femoral pulses."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fixed splitting of S2 suggests an atrial septal defect, not an obstructive lesion causing upper-lower extremity pressure dissociation."
            },
            {
              "id": "B",
              "text": "Option A: Abdominal bruit lateral to the umbilicus is inappropriate because an abdominal bruit would point more toward renovascular hypertension, which does not explain delayed femoral pulses with a large arm-thigh pressure gradient."
            },
            {
              "id": "C",
              "text": "Option C: Continuous machinery murmur at the left infraclavicular area is inappropriate because a continuous machinery murmur suggests patent ductus arteriosus rather than the discrete obstructive lesion suggested by this pressure gradient and delayed femoral pulses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fixed splitting of S2 suggests an atrial septal defect, not an obstructive lesion causing upper-lower extremity pressure dissociation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Late-peaking crescendo-decrescendo murmur at the right upper sternal border radiating to the carotids is inappropriate because aortic stenosis can radiate to the carotids, but it does not explain weaker delayed femoral pulses with lower leg pressures than arm pressures."
            },
            {
              "id": "B",
              "text": "Option A: Abdominal bruit lateral to the umbilicus is inappropriate because an abdominal bruit would point more toward renovascular hypertension, which does not explain delayed femoral pulses with a large arm-thigh pressure gradient."
            },
            {
              "id": "C",
              "text": "Option C: Continuous machinery murmur at the left infraclavicular area is inappropriate because a continuous machinery murmur suggests patent ductus arteriosus rather than the discrete obstructive lesion suggested by this pressure gradient and delayed femoral pulses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Late-peaking crescendo-decrescendo murmur at the right upper sternal border radiating to the carotids is inappropriate because aortic stenosis can radiate to the carotids, but it does not explain weaker delayed femoral pulses with lower leg pressures than arm pressures."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Palpable left flank mass is inappropriate because a flank mass would suggest a renal cause of hypertension, but the pulse and pressure findings localize the problem to the aorta."
            },
            {
              "id": "B",
              "text": "Option A: Abdominal bruit lateral to the umbilicus is inappropriate because an abdominal bruit would point more toward renovascular hypertension, which does not explain delayed femoral pulses with a large arm-thigh pressure gradient."
            },
            {
              "id": "C",
              "text": "Option C: Continuous machinery murmur at the left infraclavicular area is inappropriate because a continuous machinery murmur suggests patent ductus arteriosus rather than the discrete obstructive lesion suggested by this pressure gradient and delayed femoral pulses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Palpable left flank mass is inappropriate because a flank mass would suggest a renal cause of hypertension, but the pulse and pressure findings localize the problem to the aorta."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Retinal hemorrhages and cotton-wool spots is inappropriate because hypertensive retinopathy can occur in severe longstanding hypertension, but the most likely additional examination finding tied to this specific lesion is the characteristic systolic murmur over the chest and back."
            },
            {
              "id": "B",
              "text": "Option A: Abdominal bruit lateral to the umbilicus is inappropriate because an abdominal bruit would point more toward renovascular hypertension, which does not explain delayed femoral pulses with a large arm-thigh pressure gradient."
            },
            {
              "id": "C",
              "text": "Option C: Continuous machinery murmur at the left infraclavicular area is inappropriate because a continuous machinery murmur suggests patent ductus arteriosus rather than the discrete obstructive lesion suggested by this pressure gradient and delayed femoral pulses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Retinal hemorrhages and cotton-wool spots is inappropriate because hypertensive retinopathy can occur in severe longstanding hypertension, but the most likely additional examination finding tied to this specific lesion is the characteristic systolic murmur over the chest and back."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i001-nocturnal-asthma-controller-step-up",
      "expectedHashes": {
        "ranaze_step3_uat": "ce4634694eb7312cfd5df23f762d0a4dcf452a10c222625caf2354a45d67c701",
        "ranaze_step3_prd": "ce4634694eb7312cfd5df23f762d0a4dcf452a10c222625caf2354a45d67c701"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Add oral prednisone at bedtime is inappropriate because chronic bedtime oral prednisone is excessive and exposes her to unnecessary systemic adverse effects for symptoms of this frequency and severity."
            },
            {
              "id": "B",
              "text": "Option B: Continue albuterol alone because spirometry is normal is inappropriate because normal spirometry between episodes does not justify continuing SABA-only treatment when symptoms occur several days per week with nighttime awakenings."
            },
            {
              "id": "C",
              "text": "Option D: Start azithromycin three times weekly is inappropriate because there is no evidence of infection, and routine azithromycin is not the appropriate next step for otherwise uncomplicated asthma symptoms like these."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Add oral prednisone at bedtime is inappropriate because chronic bedtime oral prednisone is excessive and exposes her to unnecessary systemic adverse effects for symptoms of this frequency and severity."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue albuterol alone because spirometry is normal is inappropriate because normal spirometry between episodes does not justify continuing SABA-only treatment when symptoms occur several days per week with nighttime awakenings."
            },
            {
              "id": "B",
              "text": "Option A: Add oral prednisone at bedtime is inappropriate because chronic bedtime oral prednisone is excessive and exposes her to unnecessary systemic adverse effects for symptoms of this frequency and severity."
            },
            {
              "id": "C",
              "text": "Option D: Start azithromycin three times weekly is inappropriate because there is no evidence of infection, and routine azithromycin is not the appropriate next step for otherwise uncomplicated asthma symptoms like these."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue albuterol alone because spirometry is normal is inappropriate because normal spirometry between episodes does not justify continuing SABA-only treatment when symptoms occur several days per week with nighttime awakenings."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start azithromycin three times weekly is inappropriate because there is no evidence of infection, and routine azithromycin is not the appropriate next step for otherwise uncomplicated asthma symptoms like these."
            },
            {
              "id": "B",
              "text": "Option A: Add oral prednisone at bedtime is inappropriate because chronic bedtime oral prednisone is excessive and exposes her to unnecessary systemic adverse effects for symptoms of this frequency and severity."
            },
            {
              "id": "C",
              "text": "Option B: Continue albuterol alone because spirometry is normal is inappropriate because normal spirometry between episodes does not justify continuing SABA-only treatment when symptoms occur several days per week with nighttime awakenings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start azithromycin three times weekly is inappropriate because there is no evidence of infection, and routine azithromycin is not the appropriate next step for otherwise uncomplicated asthma symptoms like these."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start tiotropium as the only controller medication is inappropriate because tiotropium is not the best first controller strategy here and should not replace inhaled corticosteroid therapy in a patient escalating from albuterol alone."
            },
            {
              "id": "B",
              "text": "Option A: Add oral prednisone at bedtime is inappropriate because chronic bedtime oral prednisone is excessive and exposes her to unnecessary systemic adverse effects for symptoms of this frequency and severity."
            },
            {
              "id": "C",
              "text": "Option B: Continue albuterol alone because spirometry is normal is inappropriate because normal spirometry between episodes does not justify continuing SABA-only treatment when symptoms occur several days per week with nighttime awakenings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start tiotropium as the only controller medication is inappropriate because tiotropium is not the best first controller strategy here and should not replace inhaled corticosteroid therapy in a patient escalating from albuterol alone."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use albuterol before bedtime every night is inappropriate because nightly albuterol adds bronchodilation without anti-inflammatory control and does not address future exacerbation risk as well as an ICS-containing regimen."
            },
            {
              "id": "B",
              "text": "Option A: Add oral prednisone at bedtime is inappropriate because chronic bedtime oral prednisone is excessive and exposes her to unnecessary systemic adverse effects for symptoms of this frequency and severity."
            },
            {
              "id": "C",
              "text": "Option B: Continue albuterol alone because spirometry is normal is inappropriate because normal spirometry between episodes does not justify continuing SABA-only treatment when symptoms occur several days per week with nighttime awakenings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use albuterol before bedtime every night is inappropriate because nightly albuterol adds bronchodilation without anti-inflammatory control and does not address future exacerbation risk as well as an ICS-containing regimen."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin daily high-dose inhaled corticosteroid plus long-acting beta agonist is inappropriate because daily high-dose ICS-LABA is more intensive than needed for this presentation."
            },
            {
              "id": "B",
              "text": "Option A: Add oral prednisone at bedtime is inappropriate because chronic bedtime oral prednisone is excessive and exposes her to unnecessary systemic adverse effects for symptoms of this frequency and severity."
            },
            {
              "id": "C",
              "text": "Option B: Continue albuterol alone because spirometry is normal is inappropriate because normal spirometry between episodes does not justify continuing SABA-only treatment when symptoms occur several days per week with nighttime awakenings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin daily high-dose inhaled corticosteroid plus long-acting beta agonist is inappropriate because daily high-dose ICS-LABA is more intensive than needed for this presentation."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i002-clarify-sexual-history-before-intervening",
      "expectedHashes": {
        "ranaze_step3_uat": "33680ba73a52ed67a79572d172760c0fef3bc60efee18291008597ce9b50b819",
        "ranaze_step3_prd": "33680ba73a52ed67a79572d172760c0fef3bc60efee18291008597ce9b50b819"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer ulipristal now is inappropriate because this is less appropriate because emergency contraception should not be given until the actual exposure is clarified."
            },
            {
              "id": "B",
              "text": "Option B: Begin depot medroxyprogesterone today is inappropriate because this is less appropriate because routine contraception may be appropriate, but the first step is to determine what sexual contact occurred and whether there is any immediate pregnancy risk."
            },
            {
              "id": "C",
              "text": "Option C: Contact adult protective services is inappropriate because this is less appropriate because the stem states that the relationship is wanted and does not provide evidence of abuse or coercion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer ulipristal now is inappropriate because this is less appropriate because emergency contraception should not be given until the actual exposure is clarified."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin depot medroxyprogesterone today is inappropriate because this is less appropriate because routine contraception may be appropriate, but the first step is to determine what sexual contact occurred and whether there is any immediate pregnancy risk."
            },
            {
              "id": "B",
              "text": "Option A: Administer ulipristal now is inappropriate because this is less appropriate because emergency contraception should not be given until the actual exposure is clarified."
            },
            {
              "id": "C",
              "text": "Option C: Contact adult protective services is inappropriate because this is less appropriate because the stem states that the relationship is wanted and does not provide evidence of abuse or coercion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin depot medroxyprogesterone today is inappropriate because this is less appropriate because routine contraception may be appropriate, but the first step is to determine what sexual contact occurred and whether there is any immediate pregnancy risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contact adult protective services is inappropriate because this is less appropriate because the stem states that the relationship is wanted and does not provide evidence of abuse or coercion."
            },
            {
              "id": "B",
              "text": "Option A: Administer ulipristal now is inappropriate because this is less appropriate because emergency contraception should not be given until the actual exposure is clarified."
            },
            {
              "id": "C",
              "text": "Option B: Begin depot medroxyprogesterone today is inappropriate because this is less appropriate because routine contraception may be appropriate, but the first step is to determine what sexual contact occurred and whether there is any immediate pregnancy risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contact adult protective services is inappropriate because this is less appropriate because the stem states that the relationship is wanted and does not provide evidence of abuse or coercion."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discuss pregnancy termination options is inappropriate because this is less appropriate because the pregnancy test is negative, so abortion counseling does not address the current question."
            },
            {
              "id": "B",
              "text": "Option A: Administer ulipristal now is inappropriate because this is less appropriate because emergency contraception should not be given until the actual exposure is clarified."
            },
            {
              "id": "C",
              "text": "Option B: Begin depot medroxyprogesterone today is inappropriate because this is less appropriate because routine contraception may be appropriate, but the first step is to determine what sexual contact occurred and whether there is any immediate pregnancy risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discuss pregnancy termination options is inappropriate because this is less appropriate because the pregnancy test is negative, so abortion counseling does not address the current question."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain contraceptive consent from her mother is inappropriate because this is less appropriate because the patient signs her own medical forms, so her mother does not automatically control contraceptive decisions."
            },
            {
              "id": "B",
              "text": "Option A: Administer ulipristal now is inappropriate because this is less appropriate because emergency contraception should not be given until the actual exposure is clarified."
            },
            {
              "id": "C",
              "text": "Option B: Begin depot medroxyprogesterone today is inappropriate because this is less appropriate because routine contraception may be appropriate, but the first step is to determine what sexual contact occurred and whether there is any immediate pregnancy risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain contraceptive consent from her mother is inappropriate because this is less appropriate because the patient signs her own medical forms, so her mother does not automatically control contraceptive decisions."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Report the boyfriend to law enforcement is inappropriate because this is less appropriate because no nonconsensual activity or other reportable offense is stated in the vignette."
            },
            {
              "id": "B",
              "text": "Option A: Administer ulipristal now is inappropriate because this is less appropriate because emergency contraception should not be given until the actual exposure is clarified."
            },
            {
              "id": "C",
              "text": "Option B: Begin depot medroxyprogesterone today is inappropriate because this is less appropriate because routine contraception may be appropriate, but the first step is to determine what sexual contact occurred and whether there is any immediate pregnancy risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Report the boyfriend to law enforcement is inappropriate because this is less appropriate because no nonconsensual activity or other reportable offense is stated in the vignette."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i003-guardianship-and-sexual-consent-capacity",
      "expectedHashes": {
        "ranaze_step3_uat": "0a7520737ac2c79ec0b4d1c456475ed871a036788f1d8c516423bf4eb7129eb4",
        "ranaze_step3_prd": "0a7520737ac2c79ec0b4d1c456475ed871a036788f1d8c516423bf4eb7129eb4"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It means she automatically has capacity to consent to sexual intercourse is inappropriate because self-guardianship alone does not automatically prove capacity to consent to sexual intercourse; sexual-consent capacity is assessed separately and is context specific."
            },
            {
              "id": "B",
              "text": "Option B: It means she is automatically capable of independently caring for an infant is inappropriate because ability to parent an infant is a different functional question and cannot be inferred solely from self-guardianship status."
            },
            {
              "id": "C",
              "text": "Option C: It means a court has already determined that all future intimate decisions are competent and voluntary is inappropriate because no prior guardianship ruling can be assumed to prospectively determine competence and voluntariness for every future intimate decision."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It means she automatically has capacity to consent to sexual intercourse is inappropriate because self-guardianship alone does not automatically prove capacity to consent to sexual intercourse; sexual-consent capacity is assessed separately and is context specific."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It means she is automatically capable of independently caring for an infant is inappropriate because ability to parent an infant is a different functional question and cannot be inferred solely from self-guardianship status."
            },
            {
              "id": "B",
              "text": "Option A: It means she automatically has capacity to consent to sexual intercourse is inappropriate because self-guardianship alone does not automatically prove capacity to consent to sexual intercourse; sexual-consent capacity is assessed separately and is context specific."
            },
            {
              "id": "C",
              "text": "Option C: It means a court has already determined that all future intimate decisions are competent and voluntary is inappropriate because no prior guardianship ruling can be assumed to prospectively determine competence and voluntariness for every future intimate decision."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It means she is automatically capable of independently caring for an infant is inappropriate because ability to parent an infant is a different functional question and cannot be inferred solely from self-guardianship status."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It means a court has already determined that all future intimate decisions are competent and voluntary is inappropriate because no prior guardianship ruling can be assumed to prospectively determine competence and voluntariness for every future intimate decision."
            },
            {
              "id": "B",
              "text": "Option A: It means she automatically has capacity to consent to sexual intercourse is inappropriate because self-guardianship alone does not automatically prove capacity to consent to sexual intercourse; sexual-consent capacity is assessed separately and is context specific."
            },
            {
              "id": "C",
              "text": "Option B: It means she is automatically capable of independently caring for an infant is inappropriate because ability to parent an infant is a different functional question and cannot be inferred solely from self-guardianship status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It means a court has already determined that all future intimate decisions are competent and voluntary is inappropriate because no prior guardianship ruling can be assumed to prospectively determine competence and voluntariness for every future intimate decision."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It has no relevance at all to any question about decision-making ability is inappropriate because self-guardianship is contextual information, but it is not dispositive; saying it has no relevance at all is too absolute."
            },
            {
              "id": "B",
              "text": "Option A: It means she automatically has capacity to consent to sexual intercourse is inappropriate because self-guardianship alone does not automatically prove capacity to consent to sexual intercourse; sexual-consent capacity is assessed separately and is context specific."
            },
            {
              "id": "C",
              "text": "Option B: It means she is automatically capable of independently caring for an infant is inappropriate because ability to parent an infant is a different functional question and cannot be inferred solely from self-guardianship status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It has no relevance at all to any question about decision-making ability is inappropriate because self-guardianship is contextual information, but it is not dispositive; saying it has no relevance at all is too absolute."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It suggests the prior judge probably made a legal error is inappropriate because there is no basis for concluding that the prior court acted improperly simply because the patient is now her own guardian."
            },
            {
              "id": "B",
              "text": "Option A: It means she automatically has capacity to consent to sexual intercourse is inappropriate because self-guardianship alone does not automatically prove capacity to consent to sexual intercourse; sexual-consent capacity is assessed separately and is context specific."
            },
            {
              "id": "C",
              "text": "Option B: It means she is automatically capable of independently caring for an infant is inappropriate because ability to parent an infant is a different functional question and cannot be inferred solely from self-guardianship status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It suggests the prior judge probably made a legal error is inappropriate because there is no basis for concluding that the prior court acted improperly simply because the patient is now her own guardian."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It means sexual activity with her can never be considered exploitative is inappropriate because a person may still be exploited even if she is her own guardian; self-guardianship does not eliminate the need to assess coercion, voluntariness, and decision-specific capacity."
            },
            {
              "id": "B",
              "text": "Option A: It means she automatically has capacity to consent to sexual intercourse is inappropriate because self-guardianship alone does not automatically prove capacity to consent to sexual intercourse; sexual-consent capacity is assessed separately and is context specific."
            },
            {
              "id": "C",
              "text": "Option B: It means she is automatically capable of independently caring for an infant is inappropriate because ability to parent an infant is a different functional question and cannot be inferred solely from self-guardianship status."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It means sexual activity with her can never be considered exploitative is inappropriate because a person may still be exploited even if she is her own guardian; self-guardianship does not eliminate the need to assess coercion, voluntariness, and decision-specific capacity."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i004-rapid-imaging-for-diabetic-foot-gas",
      "expectedHashes": {
        "ranaze_step3_uat": "90f1f08b2c666db5188684ded198f34eb79abbcff569b0fa35ac5d15a8d287f5",
        "ranaze_step3_prd": "90f1f08b2c666db5188684ded198f34eb79abbcff569b0fa35ac5d15a8d287f5"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Duplex arterial ultrasonography of the left leg is inappropriate because arterial duplex studies evaluate limb ischemia, but the stem points to fulminant soft-tissue infection rather than arterial insufficiency."
            },
            {
              "id": "B",
              "text": "Option B: CT angiography of the left leg is inappropriate because cT angiography is not the best immediate study for suspected gas-forming soft-tissue infection and would add unnecessary delay."
            },
            {
              "id": "C",
              "text": "Option D: MRI of the left foot and lower leg is inappropriate because mRI is slower and is unnecessary when necrotizing infection with crepitus already requires urgent surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Duplex arterial ultrasonography of the left leg is inappropriate because arterial duplex studies evaluate limb ischemia, but the stem points to fulminant soft-tissue infection rather than arterial insufficiency."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT angiography of the left leg is inappropriate because cT angiography is not the best immediate study for suspected gas-forming soft-tissue infection and would add unnecessary delay."
            },
            {
              "id": "B",
              "text": "Option A: Duplex arterial ultrasonography of the left leg is inappropriate because arterial duplex studies evaluate limb ischemia, but the stem points to fulminant soft-tissue infection rather than arterial insufficiency."
            },
            {
              "id": "C",
              "text": "Option D: MRI of the left foot and lower leg is inappropriate because mRI is slower and is unnecessary when necrotizing infection with crepitus already requires urgent surgery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT angiography of the left leg is inappropriate because cT angiography is not the best immediate study for suspected gas-forming soft-tissue infection and would add unnecessary delay."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the left foot and lower leg is inappropriate because mRI is slower and is unnecessary when necrotizing infection with crepitus already requires urgent surgery."
            },
            {
              "id": "B",
              "text": "Option A: Duplex arterial ultrasonography of the left leg is inappropriate because arterial duplex studies evaluate limb ischemia, but the stem points to fulminant soft-tissue infection rather than arterial insufficiency."
            },
            {
              "id": "C",
              "text": "Option B: CT angiography of the left leg is inappropriate because cT angiography is not the best immediate study for suspected gas-forming soft-tissue infection and would add unnecessary delay."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the left foot and lower leg is inappropriate because mRI is slower and is unnecessary when necrotizing infection with crepitus already requires urgent surgery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radionuclide bone scan is inappropriate because bone scan is too slow and is used more for subacute osteomyelitis questions than for an acutely toxic patient with suspected soft-tissue gas."
            },
            {
              "id": "B",
              "text": "Option A: Duplex arterial ultrasonography of the left leg is inappropriate because arterial duplex studies evaluate limb ischemia, but the stem points to fulminant soft-tissue infection rather than arterial insufficiency."
            },
            {
              "id": "C",
              "text": "Option B: CT angiography of the left leg is inappropriate because cT angiography is not the best immediate study for suspected gas-forming soft-tissue infection and would add unnecessary delay."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radionuclide bone scan is inappropriate because bone scan is too slow and is used more for subacute osteomyelitis questions than for an acutely toxic patient with suspected soft-tissue gas."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contrast venography of the left leg is inappropriate because venography evaluates venous thrombosis, not gas-forming foot infection."
            },
            {
              "id": "B",
              "text": "Option A: Duplex arterial ultrasonography of the left leg is inappropriate because arterial duplex studies evaluate limb ischemia, but the stem points to fulminant soft-tissue infection rather than arterial insufficiency."
            },
            {
              "id": "C",
              "text": "Option B: CT angiography of the left leg is inappropriate because cT angiography is not the best immediate study for suspected gas-forming soft-tissue infection and would add unnecessary delay."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contrast venography of the left leg is inappropriate because venography evaluates venous thrombosis, not gas-forming foot infection."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bedside soft-tissue ultrasonography of the left foot is inappropriate because soft-tissue ultrasonography is not the best rapid study to show the extent of gas in this scenario."
            },
            {
              "id": "B",
              "text": "Option A: Duplex arterial ultrasonography of the left leg is inappropriate because arterial duplex studies evaluate limb ischemia, but the stem points to fulminant soft-tissue infection rather than arterial insufficiency."
            },
            {
              "id": "C",
              "text": "Option B: CT angiography of the left leg is inappropriate because cT angiography is not the best immediate study for suspected gas-forming soft-tissue infection and would add unnecessary delay."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bedside soft-tissue ultrasonography of the left foot is inappropriate because soft-tissue ultrasonography is not the best rapid study to show the extent of gas in this scenario."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i006-periungual-fibroma-with-seizure-syndrome",
      "expectedHashes": {
        "ranaze_step3_uat": "018e5db93275e8704435577ec1b3887611137cf1587cc29d312b48ce46caba60",
        "ranaze_step3_prd": "018e5db93275e8704435577ec1b3887611137cf1587cc29d312b48ce46caba60"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Birt-Hogg-Dube syndrome is associated with fibrofolliculomas, lung cysts, spontaneous pneumothorax, and renal tumors rather than childhood seizures with cortical tubers and periungual fibromas."
            },
            {
              "id": "B",
              "text": "Option B: Neurofibromatosis type 2 causes bilateral vestibular schwannomas, meningiomas, and ependymomas; the nail lesion and cortical hamartomas do not fit."
            },
            {
              "id": "C",
              "text": "Option C: Pseudoxanthoma elasticum causes calcification of elastic tissue with skin papules, retinal angioid streaks, and vascular disease, not this neurocutaneous seizure syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Birt-Hogg-Dube syndrome is associated with fibrofolliculomas, lung cysts, spontaneous pneumothorax, and renal tumors rather than childhood seizures with cortical tubers and periungual fibromas."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neurofibromatosis type 2 causes bilateral vestibular schwannomas, meningiomas, and ependymomas; the nail lesion and cortical hamartomas do not fit."
            },
            {
              "id": "B",
              "text": "Option A: Birt-Hogg-Dube syndrome is associated with fibrofolliculomas, lung cysts, spontaneous pneumothorax, and renal tumors rather than childhood seizures with cortical tubers and periungual fibromas."
            },
            {
              "id": "C",
              "text": "Option C: Pseudoxanthoma elasticum causes calcification of elastic tissue with skin papules, retinal angioid streaks, and vascular disease, not this neurocutaneous seizure syndrome."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neurofibromatosis type 2 causes bilateral vestibular schwannomas, meningiomas, and ependymomas; the nail lesion and cortical hamartomas do not fit."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pseudoxanthoma elasticum causes calcification of elastic tissue with skin papules, retinal angioid streaks, and vascular disease, not this neurocutaneous seizure syndrome."
            },
            {
              "id": "B",
              "text": "Option A: Birt-Hogg-Dube syndrome is associated with fibrofolliculomas, lung cysts, spontaneous pneumothorax, and renal tumors rather than childhood seizures with cortical tubers and periungual fibromas."
            },
            {
              "id": "C",
              "text": "Option B: Neurofibromatosis type 2 causes bilateral vestibular schwannomas, meningiomas, and ependymomas; the nail lesion and cortical hamartomas do not fit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pseudoxanthoma elasticum causes calcification of elastic tissue with skin papules, retinal angioid streaks, and vascular disease, not this neurocutaneous seizure syndrome."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sturge-Weber syndrome is characterized by a facial port-wine stain, leptomeningeal angiomas, and glaucoma rather than periungual fibromas and subependymal nodules."
            },
            {
              "id": "B",
              "text": "Option A: Birt-Hogg-Dube syndrome is associated with fibrofolliculomas, lung cysts, spontaneous pneumothorax, and renal tumors rather than childhood seizures with cortical tubers and periungual fibromas."
            },
            {
              "id": "C",
              "text": "Option B: Neurofibromatosis type 2 causes bilateral vestibular schwannomas, meningiomas, and ependymomas; the nail lesion and cortical hamartomas do not fit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sturge-Weber syndrome is characterized by a facial port-wine stain, leptomeningeal angiomas, and glaucoma rather than periungual fibromas and subependymal nodules."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Von Hippel-Lindau disease features hemangioblastomas, renal cell carcinoma, and pheochromocytoma rather than periungual fibromas with cortical tubers."
            },
            {
              "id": "B",
              "text": "Option A: Birt-Hogg-Dube syndrome is associated with fibrofolliculomas, lung cysts, spontaneous pneumothorax, and renal tumors rather than childhood seizures with cortical tubers and periungual fibromas."
            },
            {
              "id": "C",
              "text": "Option B: Neurofibromatosis type 2 causes bilateral vestibular schwannomas, meningiomas, and ependymomas; the nail lesion and cortical hamartomas do not fit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Von Hippel-Lindau disease features hemangioblastomas, renal cell carcinoma, and pheochromocytoma rather than periungual fibromas with cortical tubers."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nail-patella syndrome causes nail dysplasia, hypoplastic patellae, and nephropathy, not epilepsy with intracranial hamartomas."
            },
            {
              "id": "B",
              "text": "Option A: Birt-Hogg-Dube syndrome is associated with fibrofolliculomas, lung cysts, spontaneous pneumothorax, and renal tumors rather than childhood seizures with cortical tubers and periungual fibromas."
            },
            {
              "id": "C",
              "text": "Option B: Neurofibromatosis type 2 causes bilateral vestibular schwannomas, meningiomas, and ependymomas; the nail lesion and cortical hamartomas do not fit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nail-patella syndrome causes nail dysplasia, hypoplastic patellae, and nephropathy, not epilepsy with intracranial hamartomas."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i012-acute-compartment-syndrome-fasciotomy",
      "expectedHashes": {
        "ranaze_step3_uat": "7921e77bec4077d60906e8d6da8aaa6f51b7ecc573824914fb228ed7b8294432",
        "ranaze_step3_prd": "7921e77bec4077d60906e8d6da8aaa6f51b7ecc573824914fb228ed7b8294432"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Below-knee amputation is inappropriate because amputation is not the initial step because the limb may still be salvageable with urgent decompression."
            },
            {
              "id": "B",
              "text": "Option B: Immediate external fixation of the fracture is inappropriate because fracture stabilization does not treat the immediately limb-threatening rise in compartment pressure."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous unfractionated heparin is inappropriate because heparin is used for acute thrombosis, not for compartment syndrome caused by tissue swelling within a closed fascial space."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Below-knee amputation is inappropriate because amputation is not the initial step because the limb may still be salvageable with urgent decompression."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate external fixation of the fracture is inappropriate because fracture stabilization does not treat the immediately limb-threatening rise in compartment pressure."
            },
            {
              "id": "B",
              "text": "Option A: Below-knee amputation is inappropriate because amputation is not the initial step because the limb may still be salvageable with urgent decompression."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous unfractionated heparin is inappropriate because heparin is used for acute thrombosis, not for compartment syndrome caused by tissue swelling within a closed fascial space."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate external fixation of the fracture is inappropriate because fracture stabilization does not treat the immediately limb-threatening rise in compartment pressure."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous unfractionated heparin is inappropriate because heparin is used for acute thrombosis, not for compartment syndrome caused by tissue swelling within a closed fascial space."
            },
            {
              "id": "B",
              "text": "Option A: Below-knee amputation is inappropriate because amputation is not the initial step because the limb may still be salvageable with urgent decompression."
            },
            {
              "id": "C",
              "text": "Option B: Immediate external fixation of the fracture is inappropriate because fracture stabilization does not treat the immediately limb-threatening rise in compartment pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous unfractionated heparin is inappropriate because heparin is used for acute thrombosis, not for compartment syndrome caused by tissue swelling within a closed fascial space."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower-extremity angiography is inappropriate because angiography would delay definitive treatment; the clinical picture already indicates compartment syndrome."
            },
            {
              "id": "B",
              "text": "Option A: Below-knee amputation is inappropriate because amputation is not the initial step because the limb may still be salvageable with urgent decompression."
            },
            {
              "id": "C",
              "text": "Option B: Immediate external fixation of the fracture is inappropriate because fracture stabilization does not treat the immediately limb-threatening rise in compartment pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower-extremity angiography is inappropriate because angiography would delay definitive treatment; the clinical picture already indicates compartment syndrome."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Popliteal-to-pedal bypass grafting is inappropriate because bypass grafting would be considered for a defined arterial injury, which is not the primary problem here."
            },
            {
              "id": "B",
              "text": "Option A: Below-knee amputation is inappropriate because amputation is not the initial step because the limb may still be salvageable with urgent decompression."
            },
            {
              "id": "C",
              "text": "Option B: Immediate external fixation of the fracture is inappropriate because fracture stabilization does not treat the immediately limb-threatening rise in compartment pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Popliteal-to-pedal bypass grafting is inappropriate because bypass grafting would be considered for a defined arterial injury, which is not the primary problem here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serial observation with repeat neurovascular examinations in 6 hours is inappropriate because observation is inappropriate because neurologic deficits and a tense compartment indicate an emergency."
            },
            {
              "id": "B",
              "text": "Option A: Below-knee amputation is inappropriate because amputation is not the initial step because the limb may still be salvageable with urgent decompression."
            },
            {
              "id": "C",
              "text": "Option B: Immediate external fixation of the fracture is inappropriate because fracture stabilization does not treat the immediately limb-threatening rise in compartment pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serial observation with repeat neurovascular examinations in 6 hours is inappropriate because observation is inappropriate because neurologic deficits and a tense compartment indicate an emergency."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i013-asymptomatic-hepatocellular-pattern-hepatitis-c",
      "expectedHashes": {
        "ranaze_step3_uat": "30df9b46ef2f31344f59add0e6ba7d4367b21c36b349883bd90666dbeae1786b",
        "ranaze_step3_prd": "30df9b46ef2f31344f59add0e6ba7d4367b21c36b349883bd90666dbeae1786b"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Alcohol-associated hepatitis usually has heavier alcohol exposure and often an AST:ALT ratio greater than 2, which is not present here."
            },
            {
              "id": "B",
              "text": "Option C: Choledocholithiasis typically causes a cholestatic pattern with elevated alkaline phosphatase and often bilirubin elevation or biliary symptoms."
            },
            {
              "id": "C",
              "text": "Option D: Gilbert syndrome causes isolated unconjugated hyperbilirubinemia, not elevated aminotransferases with normal bilirubin."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Alcohol-associated hepatitis usually has heavier alcohol exposure and often an AST:ALT ratio greater than 2, which is not present here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Choledocholithiasis typically causes a cholestatic pattern with elevated alkaline phosphatase and often bilirubin elevation or biliary symptoms."
            },
            {
              "id": "B",
              "text": "Option A: Alcohol-associated hepatitis usually has heavier alcohol exposure and often an AST:ALT ratio greater than 2, which is not present here."
            },
            {
              "id": "C",
              "text": "Option D: Gilbert syndrome causes isolated unconjugated hyperbilirubinemia, not elevated aminotransferases with normal bilirubin."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Choledocholithiasis typically causes a cholestatic pattern with elevated alkaline phosphatase and often bilirubin elevation or biliary symptoms."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gilbert syndrome causes isolated unconjugated hyperbilirubinemia, not elevated aminotransferases with normal bilirubin."
            },
            {
              "id": "B",
              "text": "Option A: Alcohol-associated hepatitis usually has heavier alcohol exposure and often an AST:ALT ratio greater than 2, which is not present here."
            },
            {
              "id": "C",
              "text": "Option C: Choledocholithiasis typically causes a cholestatic pattern with elevated alkaline phosphatase and often bilirubin elevation or biliary symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gilbert syndrome causes isolated unconjugated hyperbilirubinemia, not elevated aminotransferases with normal bilirubin."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Primary biliary cholangitis usually presents with cholestatic liver tests, especially elevated alkaline phosphatase, often with pruritus or fatigue."
            },
            {
              "id": "B",
              "text": "Option A: Alcohol-associated hepatitis usually has heavier alcohol exposure and often an AST:ALT ratio greater than 2, which is not present here."
            },
            {
              "id": "C",
              "text": "Option C: Choledocholithiasis typically causes a cholestatic pattern with elevated alkaline phosphatase and often bilirubin elevation or biliary symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Primary biliary cholangitis usually presents with cholestatic liver tests, especially elevated alkaline phosphatase, often with pruritus or fatigue."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute acetaminophen hepatotoxicity is inappropriate because acetaminophen hepatotoxicity causes marked aminotransferase elevation, often into the thousands, not a stable mild pattern in a well patient."
            },
            {
              "id": "B",
              "text": "Option A: Alcohol-associated hepatitis usually has heavier alcohol exposure and often an AST:ALT ratio greater than 2, which is not present here."
            },
            {
              "id": "C",
              "text": "Option C: Choledocholithiasis typically causes a cholestatic pattern with elevated alkaline phosphatase and often bilirubin elevation or biliary symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute acetaminophen hepatotoxicity is inappropriate because acetaminophen hepatotoxicity causes marked aminotransferase elevation, often into the thousands, not a stable mild pattern in a well patient."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Metastatic obstruction of the liver is inappropriate because metastatic obstruction more often produces cholestatic abnormalities or systemic signs rather than isolated mild hepatocellular enzyme elevation."
            },
            {
              "id": "B",
              "text": "Option A: Alcohol-associated hepatitis usually has heavier alcohol exposure and often an AST:ALT ratio greater than 2, which is not present here."
            },
            {
              "id": "C",
              "text": "Option C: Choledocholithiasis typically causes a cholestatic pattern with elevated alkaline phosphatase and often bilirubin elevation or biliary symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Metastatic obstruction of the liver is inappropriate because metastatic obstruction more often produces cholestatic abnormalities or systemic signs rather than isolated mild hepatocellular enzyme elevation."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i015-copd-with-community-pneumonia-levofloxacin",
      "expectedHashes": {
        "ranaze_step3_uat": "c5453a23b8ba85d67cc38897dd93cda72d17441aea561ea485092cc83e40e0b7",
        "ranaze_step3_prd": "c5453a23b8ba85d67cc38897dd93cda72d17441aea561ea485092cc83e40e0b7"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amoxicillin alone is inadequate empiric therapy here, especially for hospitalized CAP with comorbid lung disease."
            },
            {
              "id": "B",
              "text": "Option B: Azithromycin monotherapy is not preferred for this hospitalized patient."
            },
            {
              "id": "C",
              "text": "Option C: Cefazolin is not a standard empiric agent for community-acquired pneumonia and is additionally unattractive with a prior urticarial ceftriaxone reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amoxicillin alone is inadequate empiric therapy here, especially for hospitalized CAP with comorbid lung disease."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Azithromycin monotherapy is not preferred for this hospitalized patient."
            },
            {
              "id": "B",
              "text": "Option A: Amoxicillin alone is inadequate empiric therapy here, especially for hospitalized CAP with comorbid lung disease."
            },
            {
              "id": "C",
              "text": "Option C: Cefazolin is not a standard empiric agent for community-acquired pneumonia and is additionally unattractive with a prior urticarial ceftriaxone reaction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Azithromycin monotherapy is not preferred for this hospitalized patient."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cefazolin is not a standard empiric agent for community-acquired pneumonia and is additionally unattractive with a prior urticarial ceftriaxone reaction."
            },
            {
              "id": "B",
              "text": "Option A: Amoxicillin alone is inadequate empiric therapy here, especially for hospitalized CAP with comorbid lung disease."
            },
            {
              "id": "C",
              "text": "Option B: Azithromycin monotherapy is not preferred for this hospitalized patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cefazolin is not a standard empiric agent for community-acquired pneumonia and is additionally unattractive with a prior urticarial ceftriaxone reaction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Doxycycline alone is generally insufficient for hospitalized CAP in this setting."
            },
            {
              "id": "B",
              "text": "Option A: Amoxicillin alone is inadequate empiric therapy here, especially for hospitalized CAP with comorbid lung disease."
            },
            {
              "id": "C",
              "text": "Option B: Azithromycin monotherapy is not preferred for this hospitalized patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Doxycycline alone is generally insufficient for hospitalized CAP in this setting."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Metronidazole targets anaerobes and does not provide standard empiric CAP coverage."
            },
            {
              "id": "B",
              "text": "Option A: Amoxicillin alone is inadequate empiric therapy here, especially for hospitalized CAP with comorbid lung disease."
            },
            {
              "id": "C",
              "text": "Option B: Azithromycin monotherapy is not preferred for this hospitalized patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Metronidazole targets anaerobes and does not provide standard empiric CAP coverage."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Trimethoprim-sulfamethoxazole is not standard empiric therapy for community-acquired pneumonia."
            },
            {
              "id": "B",
              "text": "Option A: Amoxicillin alone is inadequate empiric therapy here, especially for hospitalized CAP with comorbid lung disease."
            },
            {
              "id": "C",
              "text": "Option B: Azithromycin monotherapy is not preferred for this hospitalized patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Trimethoprim-sulfamethoxazole is not standard empiric therapy for community-acquired pneumonia."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i017-execution-ethics-boundary",
      "expectedHashes": {
        "ranaze_step3_uat": "a381866edecb389c0876cf78611a5848cbe187753adaf083420cffae4af523b5",
        "ranaze_step3_prd": "a381866edecb389c0876cf78611a5848cbe187753adaf083420cffae4af523b5"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Advise on drug dosing only, as long as you do not enter the execution chamber is inappropriate because advising on drug dosing during the execution is direct participation, not an ethically acceptable workaround."
            },
            {
              "id": "B",
              "text": "Option B: Participate because the requested duties are authorized by state law is inappropriate because legal authorization by a state does not make physician participation ethically acceptable under professional standards."
            },
            {
              "id": "C",
              "text": "Option C: Refer the prison to another physician who is willing to help is inappropriate because referring the prison to another physician still facilitates physician participation in the execution."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Advise on drug dosing only, as long as you do not enter the execution chamber is inappropriate because advising on drug dosing during the execution is direct participation, not an ethically acceptable workaround."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Participate because the requested duties are authorized by state law is inappropriate because legal authorization by a state does not make physician participation ethically acceptable under professional standards."
            },
            {
              "id": "B",
              "text": "Option A: Advise on drug dosing only, as long as you do not enter the execution chamber is inappropriate because advising on drug dosing during the execution is direct participation, not an ethically acceptable workaround."
            },
            {
              "id": "C",
              "text": "Option C: Refer the prison to another physician who is willing to help is inappropriate because referring the prison to another physician still facilitates physician participation in the execution."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Participate because the requested duties are authorized by state law is inappropriate because legal authorization by a state does not make physician participation ethically acceptable under professional standards."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer the prison to another physician who is willing to help is inappropriate because referring the prison to another physician still facilitates physician participation in the execution."
            },
            {
              "id": "B",
              "text": "Option A: Advise on drug dosing only, as long as you do not enter the execution chamber is inappropriate because advising on drug dosing during the execution is direct participation, not an ethically acceptable workaround."
            },
            {
              "id": "C",
              "text": "Option B: Participate because the requested duties are authorized by state law is inappropriate because legal authorization by a state does not make physician participation ethically acceptable under professional standards."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer the prison to another physician who is willing to help is inappropriate because referring the prison to another physician still facilitates physician participation in the execution."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Limit your role to placing the intravenous line and monitoring unconsciousness is inappropriate because placing the intravenous line and monitoring unconsciousness are direct components of the execution process."
            },
            {
              "id": "B",
              "text": "Option A: Advise on drug dosing only, as long as you do not enter the execution chamber is inappropriate because advising on drug dosing during the execution is direct participation, not an ethically acceptable workaround."
            },
            {
              "id": "C",
              "text": "Option B: Participate because the requested duties are authorized by state law is inappropriate because legal authorization by a state does not make physician participation ethically acceptable under professional standards."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Limit your role to placing the intravenous line and monitoring unconsciousness is inappropriate because placing the intravenous line and monitoring unconsciousness are direct components of the execution process."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Participate if the inmate signs a consent form for your involvement is inappropriate because the inmate\u0027s consent does not make physician participation ethically permissible."
            },
            {
              "id": "B",
              "text": "Option A: Advise on drug dosing only, as long as you do not enter the execution chamber is inappropriate because advising on drug dosing during the execution is direct participation, not an ethically acceptable workaround."
            },
            {
              "id": "C",
              "text": "Option B: Participate because the requested duties are authorized by state law is inappropriate because legal authorization by a state does not make physician participation ethically acceptable under professional standards."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Participate if the inmate signs a consent form for your involvement is inappropriate because the inmate\u0027s consent does not make physician participation ethically permissible."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask the hospital to decide based on malpractice coverage is inappropriate because malpractice coverage is not the central issue; the request itself is ethically impermissible."
            },
            {
              "id": "B",
              "text": "Option A: Advise on drug dosing only, as long as you do not enter the execution chamber is inappropriate because advising on drug dosing during the execution is direct participation, not an ethically acceptable workaround."
            },
            {
              "id": "C",
              "text": "Option B: Participate because the requested duties are authorized by state law is inappropriate because legal authorization by a state does not make physician participation ethically acceptable under professional standards."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask the hospital to decide based on malpractice coverage is inappropriate because malpractice coverage is not the central issue; the request itself is ethically impermissible."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i018-painful-posterior-vulvar-mass",
      "expectedHashes": {
        "ranaze_step3_uat": "9b8dbf333938e4b75f8bc196a1994412ba17eee577d33747ece26decb80c616e",
        "ranaze_step3_prd": "9b8dbf333938e4b75f8bc196a1994412ba17eee577d33747ece26decb80c616e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An epidermal inclusion cyst is usually a noninflamed, subcutaneous nodule and would not typically drain purulence from a duct opening at the posterolateral vestibule."
            },
            {
              "id": "B",
              "text": "Option B: Genital herpes simplex infection is inappropriate because herpes causes painful vesicles or ulcers rather than a single fluctuant mass with purulent duct drainage."
            },
            {
              "id": "C",
              "text": "Option C: Hidradenitis suppurativa is inappropriate because hidradenitis causes recurrent nodules, abscesses, and sinus tracts in apocrine-bearing areas, not an isolated duct-based vestibular mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An epidermal inclusion cyst is usually a noninflamed, subcutaneous nodule and would not typically drain purulence from a duct opening at the posterolateral vestibule."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Genital herpes simplex infection is inappropriate because herpes causes painful vesicles or ulcers rather than a single fluctuant mass with purulent duct drainage."
            },
            {
              "id": "B",
              "text": "Option A: An epidermal inclusion cyst is usually a noninflamed, subcutaneous nodule and would not typically drain purulence from a duct opening at the posterolateral vestibule."
            },
            {
              "id": "C",
              "text": "Option C: Hidradenitis suppurativa is inappropriate because hidradenitis causes recurrent nodules, abscesses, and sinus tracts in apocrine-bearing areas, not an isolated duct-based vestibular mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Genital herpes simplex infection is inappropriate because herpes causes painful vesicles or ulcers rather than a single fluctuant mass with purulent duct drainage."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hidradenitis suppurativa is inappropriate because hidradenitis causes recurrent nodules, abscesses, and sinus tracts in apocrine-bearing areas, not an isolated duct-based vestibular mass."
            },
            {
              "id": "B",
              "text": "Option A: An epidermal inclusion cyst is usually a noninflamed, subcutaneous nodule and would not typically drain purulence from a duct opening at the posterolateral vestibule."
            },
            {
              "id": "C",
              "text": "Option B: Genital herpes simplex infection is inappropriate because herpes causes painful vesicles or ulcers rather than a single fluctuant mass with purulent duct drainage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hidradenitis suppurativa is inappropriate because hidradenitis causes recurrent nodules, abscesses, and sinus tracts in apocrine-bearing areas, not an isolated duct-based vestibular mass."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An indirect inguinal hernia presents in the inguinal region, not as a tender fluctuant lesion at the posterolateral vestibule."
            },
            {
              "id": "B",
              "text": "Option A: An epidermal inclusion cyst is usually a noninflamed, subcutaneous nodule and would not typically drain purulence from a duct opening at the posterolateral vestibule."
            },
            {
              "id": "C",
              "text": "Option B: Genital herpes simplex infection is inappropriate because herpes causes painful vesicles or ulcers rather than a single fluctuant mass with purulent duct drainage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An indirect inguinal hernia presents in the inguinal region, not as a tender fluctuant lesion at the posterolateral vestibule."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A lipoma is soft and nontender, not acutely painful, erythematous, or purulent."
            },
            {
              "id": "B",
              "text": "Option A: An epidermal inclusion cyst is usually a noninflamed, subcutaneous nodule and would not typically drain purulence from a duct opening at the posterolateral vestibule."
            },
            {
              "id": "C",
              "text": "Option B: Genital herpes simplex infection is inappropriate because herpes causes painful vesicles or ulcers rather than a single fluctuant mass with purulent duct drainage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A lipoma is soft and nontender, not acutely painful, erythematous, or purulent."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vulvar squamous cell carcinoma is usually a chronic ulcerative or exophytic lesion rather than a 4-day fluctuant purulent swelling."
            },
            {
              "id": "B",
              "text": "Option A: An epidermal inclusion cyst is usually a noninflamed, subcutaneous nodule and would not typically drain purulence from a duct opening at the posterolateral vestibule."
            },
            {
              "id": "C",
              "text": "Option B: Genital herpes simplex infection is inappropriate because herpes causes painful vesicles or ulcers rather than a single fluctuant mass with purulent duct drainage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vulvar squamous cell carcinoma is usually a chronic ulcerative or exophytic lesion rather than a 4-day fluctuant purulent swelling."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i020-supportive-care-for-enteroviral-stomatitis",
      "expectedHashes": {
        "ranaze_step3_uat": "3854275d06a4eb23bf130f86c20e26908bc6042b6f5e1012fa0e764902e8bbe0",
        "ranaze_step3_prd": "3854275d06a4eb23bf130f86c20e26908bc6042b6f5e1012fa0e764902e8bbe0"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral acyclovir is inappropriate because acyclovir is used for herpesvirus infections, not routine enteroviral hand-foot-and-mouth disease."
            },
            {
              "id": "B",
              "text": "Option B: Oral amoxicillin is inappropriate because amoxicillin is not indicated for this viral syndrome and would not help the oral ulcers or palmoplantar rash."
            },
            {
              "id": "C",
              "text": "Option C: Oral fluconazole is inappropriate because fluconazole treats fungal infections such as candidiasis, which does not present with this hand-and-foot exanthem."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral acyclovir is inappropriate because acyclovir is used for herpesvirus infections, not routine enteroviral hand-foot-and-mouth disease."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral amoxicillin is inappropriate because amoxicillin is not indicated for this viral syndrome and would not help the oral ulcers or palmoplantar rash."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpesvirus infections, not routine enteroviral hand-foot-and-mouth disease."
            },
            {
              "id": "C",
              "text": "Option C: Oral fluconazole is inappropriate because fluconazole treats fungal infections such as candidiasis, which does not present with this hand-and-foot exanthem."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral amoxicillin is inappropriate because amoxicillin is not indicated for this viral syndrome and would not help the oral ulcers or palmoplantar rash."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral fluconazole is inappropriate because fluconazole treats fungal infections such as candidiasis, which does not present with this hand-and-foot exanthem."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpesvirus infections, not routine enteroviral hand-foot-and-mouth disease."
            },
            {
              "id": "C",
              "text": "Option B: Oral amoxicillin is inappropriate because amoxicillin is not indicated for this viral syndrome and would not help the oral ulcers or palmoplantar rash."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral fluconazole is inappropriate because fluconazole treats fungal infections such as candidiasis, which does not present with this hand-and-foot exanthem."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral prednisone is inappropriate because systemic corticosteroids are not standard treatment for uncomplicated hand-foot-and-mouth disease."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpesvirus infections, not routine enteroviral hand-foot-and-mouth disease."
            },
            {
              "id": "C",
              "text": "Option B: Oral amoxicillin is inappropriate because amoxicillin is not indicated for this viral syndrome and would not help the oral ulcers or palmoplantar rash."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral prednisone is inappropriate because systemic corticosteroids are not standard treatment for uncomplicated hand-foot-and-mouth disease."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Topical mupirocin is inappropriate because mupirocin is for localized bacterial skin infection, not a viral exanthem with oral ulcers."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpesvirus infections, not routine enteroviral hand-foot-and-mouth disease."
            },
            {
              "id": "C",
              "text": "Option B: Oral amoxicillin is inappropriate because amoxicillin is not indicated for this viral syndrome and would not help the oral ulcers or palmoplantar rash."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Topical mupirocin is inappropriate because mupirocin is for localized bacterial skin infection, not a viral exanthem with oral ulcers."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oseltamivir is used for influenza and would not treat this enteroviral infection."
            },
            {
              "id": "B",
              "text": "Option A: Oral acyclovir is inappropriate because acyclovir is used for herpesvirus infections, not routine enteroviral hand-foot-and-mouth disease."
            },
            {
              "id": "C",
              "text": "Option B: Oral amoxicillin is inappropriate because amoxicillin is not indicated for this viral syndrome and would not help the oral ulcers or palmoplantar rash."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oseltamivir is used for influenza and would not treat this enteroviral infection."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i022-unstable-trauma-with-positive-fast",
      "expectedHashes": {
        "ranaze_step3_uat": "cddc0d9b25189d423d242335b7fd1131e2c2fe2b9b70f9a0b0c9fdc3ce8efe3e",
        "ranaze_step3_prd": "cddc0d9b25189d423d242335b7fd1131e2c2fe2b9b70f9a0b0c9fdc3ce8efe3e"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT scan of the chest, abdomen, and pelvis is inappropriate because cT is appropriate for hemodynamically stable trauma patients, not one with profound hypotension and a positive FAST."
            },
            {
              "id": "B",
              "text": "Option B: Diagnostic peritoneal lavage is unnecessary when FAST already shows intraperitoneal free fluid in an unstable patient."
            },
            {
              "id": "C",
              "text": "Option C: Thoracic aortography is inappropriate because a widened mediastinum raises concern for great-vessel injury, but this unstable patient with hemoperitoneum needs immediate hemorrhage control first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT scan of the chest, abdomen, and pelvis is inappropriate because cT is appropriate for hemodynamically stable trauma patients, not one with profound hypotension and a positive FAST."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diagnostic peritoneal lavage is unnecessary when FAST already shows intraperitoneal free fluid in an unstable patient."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest, abdomen, and pelvis is inappropriate because cT is appropriate for hemodynamically stable trauma patients, not one with profound hypotension and a positive FAST."
            },
            {
              "id": "C",
              "text": "Option C: Thoracic aortography is inappropriate because a widened mediastinum raises concern for great-vessel injury, but this unstable patient with hemoperitoneum needs immediate hemorrhage control first."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diagnostic peritoneal lavage is unnecessary when FAST already shows intraperitoneal free fluid in an unstable patient."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thoracic aortography is inappropriate because a widened mediastinum raises concern for great-vessel injury, but this unstable patient with hemoperitoneum needs immediate hemorrhage control first."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest, abdomen, and pelvis is inappropriate because cT is appropriate for hemodynamically stable trauma patients, not one with profound hypotension and a positive FAST."
            },
            {
              "id": "C",
              "text": "Option B: Diagnostic peritoneal lavage is unnecessary when FAST already shows intraperitoneal free fluid in an unstable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thoracic aortography is inappropriate because a widened mediastinum raises concern for great-vessel injury, but this unstable patient with hemoperitoneum needs immediate hemorrhage control first."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administration of 4 units of fresh frozen plasma only is inappropriate because plasma may be part of balanced resuscitation, but it is not the definitive next step when operative control of bleeding is required."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest, abdomen, and pelvis is inappropriate because cT is appropriate for hemodynamically stable trauma patients, not one with profound hypotension and a positive FAST."
            },
            {
              "id": "C",
              "text": "Option B: Diagnostic peritoneal lavage is unnecessary when FAST already shows intraperitoneal free fluid in an unstable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administration of 4 units of fresh frozen plasma only is inappropriate because plasma may be part of balanced resuscitation, but it is not the definitive next step when operative control of bleeding is required."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfer to interventional radiology for embolization is inappropriate because interventional radiology is generally for selected stable or transiently responsive patients; this patient needs emergent surgery."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest, abdomen, and pelvis is inappropriate because cT is appropriate for hemodynamically stable trauma patients, not one with profound hypotension and a positive FAST."
            },
            {
              "id": "C",
              "text": "Option B: Diagnostic peritoneal lavage is unnecessary when FAST already shows intraperitoneal free fluid in an unstable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfer to interventional radiology for embolization is inappropriate because interventional radiology is generally for selected stable or transiently responsive patients; this patient needs emergent surgery."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation after repeat abdominal examination is inappropriate because observation would dangerously delay definitive treatment of ongoing hemorrhagic shock."
            },
            {
              "id": "B",
              "text": "Option A: CT scan of the chest, abdomen, and pelvis is inappropriate because cT is appropriate for hemodynamically stable trauma patients, not one with profound hypotension and a positive FAST."
            },
            {
              "id": "C",
              "text": "Option B: Diagnostic peritoneal lavage is unnecessary when FAST already shows intraperitoneal free fluid in an unstable patient."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation after repeat abdominal examination is inappropriate because observation would dangerously delay definitive treatment of ongoing hemorrhagic shock."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i024-hypokalemic-hypertension-from-aldosterone-excess",
      "expectedHashes": {
        "ranaze_step3_uat": "cf38fc93ee4333af72e0068fa8a135cb46bef307303223122e914ac4e2a80f2f",
        "ranaze_step3_prd": "cf38fc93ee4333af72e0068fa8a135cb46bef307303223122e914ac4e2a80f2f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fibromuscular dysplasia causing renovascular hypertension is inappropriate because renovascular hypertension raises renin and aldosterone secondarily and more often suggests an abdominal bruit, worsening kidney function, or a clear renovascular clue."
            },
            {
              "id": "B",
              "text": "Option B: Obstructive sleep apnea with sympathetic activation is inappropriate because obstructive sleep apnea can worsen hypertension, but it does not typically cause marked hypokalemia and metabolic alkalosis."
            },
            {
              "id": "C",
              "text": "Option C: Pheochromocytoma releasing catecholamines intermittently is inappropriate because pheochromocytoma usually causes episodic headache, diaphoresis, and palpitations rather than persistent hypokalemic hypertension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fibromuscular dysplasia causing renovascular hypertension is inappropriate because renovascular hypertension raises renin and aldosterone secondarily and more often suggests an abdominal bruit, worsening kidney function, or a clear renovascular clue."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obstructive sleep apnea with sympathetic activation is inappropriate because obstructive sleep apnea can worsen hypertension, but it does not typically cause marked hypokalemia and metabolic alkalosis."
            },
            {
              "id": "B",
              "text": "Option A: Fibromuscular dysplasia causing renovascular hypertension is inappropriate because renovascular hypertension raises renin and aldosterone secondarily and more often suggests an abdominal bruit, worsening kidney function, or a clear renovascular clue."
            },
            {
              "id": "C",
              "text": "Option C: Pheochromocytoma releasing catecholamines intermittently is inappropriate because pheochromocytoma usually causes episodic headache, diaphoresis, and palpitations rather than persistent hypokalemic hypertension."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obstructive sleep apnea with sympathetic activation is inappropriate because obstructive sleep apnea can worsen hypertension, but it does not typically cause marked hypokalemia and metabolic alkalosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pheochromocytoma releasing catecholamines intermittently is inappropriate because pheochromocytoma usually causes episodic headache, diaphoresis, and palpitations rather than persistent hypokalemic hypertension."
            },
            {
              "id": "B",
              "text": "Option A: Fibromuscular dysplasia causing renovascular hypertension is inappropriate because renovascular hypertension raises renin and aldosterone secondarily and more often suggests an abdominal bruit, worsening kidney function, or a clear renovascular clue."
            },
            {
              "id": "C",
              "text": "Option B: Obstructive sleep apnea with sympathetic activation is inappropriate because obstructive sleep apnea can worsen hypertension, but it does not typically cause marked hypokalemia and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pheochromocytoma releasing catecholamines intermittently is inappropriate because pheochromocytoma usually causes episodic headache, diaphoresis, and palpitations rather than persistent hypokalemic hypertension."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Coarctation of the aorta distal to the left subclavian artery is inappropriate because coarctation causes upper-extremity hypertension with diminished lower-extremity pulses or a blood pressure gradient, not unexplained hypokalemia."
            },
            {
              "id": "B",
              "text": "Option A: Fibromuscular dysplasia causing renovascular hypertension is inappropriate because renovascular hypertension raises renin and aldosterone secondarily and more often suggests an abdominal bruit, worsening kidney function, or a clear renovascular clue."
            },
            {
              "id": "C",
              "text": "Option B: Obstructive sleep apnea with sympathetic activation is inappropriate because obstructive sleep apnea can worsen hypertension, but it does not typically cause marked hypokalemia and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Coarctation of the aorta distal to the left subclavian artery is inappropriate because coarctation causes upper-extremity hypertension with diminished lower-extremity pulses or a blood pressure gradient, not unexplained hypokalemia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Essential hypertension without a secondary cause is inappropriate because essential hypertension does not explain the concurrent hypokalemia and metabolic alkalosis."
            },
            {
              "id": "B",
              "text": "Option A: Fibromuscular dysplasia causing renovascular hypertension is inappropriate because renovascular hypertension raises renin and aldosterone secondarily and more often suggests an abdominal bruit, worsening kidney function, or a clear renovascular clue."
            },
            {
              "id": "C",
              "text": "Option B: Obstructive sleep apnea with sympathetic activation is inappropriate because obstructive sleep apnea can worsen hypertension, but it does not typically cause marked hypokalemia and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Essential hypertension without a secondary cause is inappropriate because essential hypertension does not explain the concurrent hypokalemia and metabolic alkalosis."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cushing syndrome due to excess cortisol is inappropriate because cushing syndrome can cause hypertension, but the vignette lacks typical cushingoid features and the electrolyte pattern is more directly explained by mineralocorticoid excess."
            },
            {
              "id": "B",
              "text": "Option A: Fibromuscular dysplasia causing renovascular hypertension is inappropriate because renovascular hypertension raises renin and aldosterone secondarily and more often suggests an abdominal bruit, worsening kidney function, or a clear renovascular clue."
            },
            {
              "id": "C",
              "text": "Option B: Obstructive sleep apnea with sympathetic activation is inappropriate because obstructive sleep apnea can worsen hypertension, but it does not typically cause marked hypokalemia and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cushing syndrome due to excess cortisol is inappropriate because cushing syndrome can cause hypertension, but the vignette lacks typical cushingoid features and the electrolyte pattern is more directly explained by mineralocorticoid excess."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i026-hiv-diarrhea-with-ellipsoidal-acid-fast-oocysts",
      "expectedHashes": {
        "ranaze_step3_uat": "54c887db1ddf70cf7727b862720ca746281a7c66e320d2905a6d3ad2d50104f1",
        "ranaze_step3_prd": "54c887db1ddf70cf7727b862720ca746281a7c66e320d2905a6d3ad2d50104f1"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cytomegalovirus can cause colitis in advanced HIV, but it is not identified as acid-fast ellipsoidal oocysts in stool."
            },
            {
              "id": "B",
              "text": "Option B: Cryptosporidium parvum is inappropriate because cryptosporidium is acid-fast, but its oocysts are small and round rather than large and ellipsoidal."
            },
            {
              "id": "C",
              "text": "Option C: Cyclospora cayetanensis is inappropriate because cyclospora is acid-fast and causes watery diarrhea, but the oocysts are spherical, not 28-micrometer ellipsoidal forms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cytomegalovirus can cause colitis in advanced HIV, but it is not identified as acid-fast ellipsoidal oocysts in stool."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cryptosporidium parvum is inappropriate because cryptosporidium is acid-fast, but its oocysts are small and round rather than large and ellipsoidal."
            },
            {
              "id": "B",
              "text": "Option A: Cytomegalovirus can cause colitis in advanced HIV, but it is not identified as acid-fast ellipsoidal oocysts in stool."
            },
            {
              "id": "C",
              "text": "Option C: Cyclospora cayetanensis is inappropriate because cyclospora is acid-fast and causes watery diarrhea, but the oocysts are spherical, not 28-micrometer ellipsoidal forms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cryptosporidium parvum is inappropriate because cryptosporidium is acid-fast, but its oocysts are small and round rather than large and ellipsoidal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cyclospora cayetanensis is inappropriate because cyclospora is acid-fast and causes watery diarrhea, but the oocysts are spherical, not 28-micrometer ellipsoidal forms."
            },
            {
              "id": "B",
              "text": "Option A: Cytomegalovirus can cause colitis in advanced HIV, but it is not identified as acid-fast ellipsoidal oocysts in stool."
            },
            {
              "id": "C",
              "text": "Option B: Cryptosporidium parvum is inappropriate because cryptosporidium is acid-fast, but its oocysts are small and round rather than large and ellipsoidal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cyclospora cayetanensis is inappropriate because cyclospora is acid-fast and causes watery diarrhea, but the oocysts are spherical, not 28-micrometer ellipsoidal forms."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Giardia lamblia is inappropriate because giardia causes malabsorptive diarrhea but is diagnosed by stool antigen testing or identification of cysts or trophozoites, not acid-fast oocysts."
            },
            {
              "id": "B",
              "text": "Option A: Cytomegalovirus can cause colitis in advanced HIV, but it is not identified as acid-fast ellipsoidal oocysts in stool."
            },
            {
              "id": "C",
              "text": "Option B: Cryptosporidium parvum is inappropriate because cryptosporidium is acid-fast, but its oocysts are small and round rather than large and ellipsoidal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Giardia lamblia is inappropriate because giardia causes malabsorptive diarrhea but is diagnosed by stool antigen testing or identification of cysts or trophozoites, not acid-fast oocysts."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Microsporidia can cause chronic diarrhea in AIDS, but the classic large ellipsoidal acid-fast oocyst description fits Cystoisospora better."
            },
            {
              "id": "B",
              "text": "Option A: Cytomegalovirus can cause colitis in advanced HIV, but it is not identified as acid-fast ellipsoidal oocysts in stool."
            },
            {
              "id": "C",
              "text": "Option B: Cryptosporidium parvum is inappropriate because cryptosporidium is acid-fast, but its oocysts are small and round rather than large and ellipsoidal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Microsporidia can cause chronic diarrhea in AIDS, but the classic large ellipsoidal acid-fast oocyst description fits Cystoisospora better."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Salmonella enterica is inappropriate because salmonella can cause diarrhea in HIV, but stool microscopy would not show acid-fast oocysts."
            },
            {
              "id": "B",
              "text": "Option A: Cytomegalovirus can cause colitis in advanced HIV, but it is not identified as acid-fast ellipsoidal oocysts in stool."
            },
            {
              "id": "C",
              "text": "Option B: Cryptosporidium parvum is inappropriate because cryptosporidium is acid-fast, but its oocysts are small and round rather than large and ellipsoidal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Salmonella enterica is inappropriate because salmonella can cause diarrhea in HIV, but stool microscopy would not show acid-fast oocysts."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i027-carbamazepine-associated-morbilliform-drug-eruption",
      "expectedHashes": {
        "ranaze_step3_uat": "9f940f723eaddb73d277e37d9b2f7759dd34f62ede977c9ee20e1e7bc82d48cd",
        "ranaze_step3_prd": "9f940f723eaddb73d277e37d9b2f7759dd34f62ede977c9ee20e1e7bc82d48cd"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue carbamazepine and observe for 48 hours is inappropriate because observation while continuing the likely causative medication risks progression to a more serious cutaneous adverse reaction."
            },
            {
              "id": "B",
              "text": "Option B: Add oral prednisone and continue carbamazepine is inappropriate because steroids do not replace removal of the offending drug, which is the key intervention."
            },
            {
              "id": "C",
              "text": "Option D: Stop all current medications permanently is inappropriate because it is unnecessary to stop every medication permanently when a newly started high-risk drug is the clear culprit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue carbamazepine and observe for 48 hours is inappropriate because observation while continuing the likely causative medication risks progression to a more serious cutaneous adverse reaction."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Add oral prednisone and continue carbamazepine is inappropriate because steroids do not replace removal of the offending drug, which is the key intervention."
            },
            {
              "id": "B",
              "text": "Option A: Continue carbamazepine and observe for 48 hours is inappropriate because observation while continuing the likely causative medication risks progression to a more serious cutaneous adverse reaction."
            },
            {
              "id": "C",
              "text": "Option D: Stop all current medications permanently is inappropriate because it is unnecessary to stop every medication permanently when a newly started high-risk drug is the clear culprit."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Add oral prednisone and continue carbamazepine is inappropriate because steroids do not replace removal of the offending drug, which is the key intervention."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Stop all current medications permanently is inappropriate because it is unnecessary to stop every medication permanently when a newly started high-risk drug is the clear culprit."
            },
            {
              "id": "B",
              "text": "Option A: Continue carbamazepine and observe for 48 hours is inappropriate because observation while continuing the likely causative medication risks progression to a more serious cutaneous adverse reaction."
            },
            {
              "id": "C",
              "text": "Option B: Add oral prednisone and continue carbamazepine is inappropriate because steroids do not replace removal of the offending drug, which is the key intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Stop all current medications permanently is inappropriate because it is unnecessary to stop every medication permanently when a newly started high-risk drug is the clear culprit."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Change albuterol to montelukast is inappropriate because albuterol is not the likely cause, and montelukast does not address a carbamazepine drug eruption."
            },
            {
              "id": "B",
              "text": "Option A: Continue carbamazepine and observe for 48 hours is inappropriate because observation while continuing the likely causative medication risks progression to a more serious cutaneous adverse reaction."
            },
            {
              "id": "C",
              "text": "Option B: Add oral prednisone and continue carbamazepine is inappropriate because steroids do not replace removal of the offending drug, which is the key intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Change albuterol to montelukast is inappropriate because albuterol is not the likely cause, and montelukast does not address a carbamazepine drug eruption."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat empirically with permethrin is inappropriate because scabies does not fit this medication-timed diffuse morbilliform eruption."
            },
            {
              "id": "B",
              "text": "Option A: Continue carbamazepine and observe for 48 hours is inappropriate because observation while continuing the likely causative medication risks progression to a more serious cutaneous adverse reaction."
            },
            {
              "id": "C",
              "text": "Option B: Add oral prednisone and continue carbamazepine is inappropriate because steroids do not replace removal of the offending drug, which is the key intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat empirically with permethrin is inappropriate because scabies does not fit this medication-timed diffuse morbilliform eruption."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Apply topical mupirocin only is inappropriate because mupirocin treats localized bacterial skin infection, not a generalized drug exanthem."
            },
            {
              "id": "B",
              "text": "Option A: Continue carbamazepine and observe for 48 hours is inappropriate because observation while continuing the likely causative medication risks progression to a more serious cutaneous adverse reaction."
            },
            {
              "id": "C",
              "text": "Option B: Add oral prednisone and continue carbamazepine is inappropriate because steroids do not replace removal of the offending drug, which is the key intervention."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Apply topical mupirocin only is inappropriate because mupirocin treats localized bacterial skin infection, not a generalized drug exanthem."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i030-carbapenem-seizure-antibiotic-switch",
      "expectedHashes": {
        "ranaze_step3_uat": "fdeaf8b89a86a10837aa110f42fa3308ebeda34542b4c7bedf9a1c3eeec73ae2",
        "ranaze_step3_prd": "fdeaf8b89a86a10837aa110f42fa3308ebeda34542b4c7bedf9a1c3eeec73ae2"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous alteplase is inappropriate because alteplase is not indicated for a self-limited generalized seizure without evidence of acute ischemic stroke."
            },
            {
              "id": "B",
              "text": "Option B: Administer intravenous dextrose is inappropriate because the glucose value is normal, so dextrose is unnecessary."
            },
            {
              "id": "C",
              "text": "Option C: Begin continuous intravenous midazolam infusion is inappropriate because continuous sedative infusion is used for ongoing or refractory status epilepticus, not a single brief resolved seizure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous alteplase is inappropriate because alteplase is not indicated for a self-limited generalized seizure without evidence of acute ischemic stroke."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous dextrose is inappropriate because the glucose value is normal, so dextrose is unnecessary."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous alteplase is inappropriate because alteplase is not indicated for a self-limited generalized seizure without evidence of acute ischemic stroke."
            },
            {
              "id": "C",
              "text": "Option C: Begin continuous intravenous midazolam infusion is inappropriate because continuous sedative infusion is used for ongoing or refractory status epilepticus, not a single brief resolved seizure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous dextrose is inappropriate because the glucose value is normal, so dextrose is unnecessary."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin continuous intravenous midazolam infusion is inappropriate because continuous sedative infusion is used for ongoing or refractory status epilepticus, not a single brief resolved seizure."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous alteplase is inappropriate because alteplase is not indicated for a self-limited generalized seizure without evidence of acute ischemic stroke."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous dextrose is inappropriate because the glucose value is normal, so dextrose is unnecessary."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin continuous intravenous midazolam infusion is inappropriate because continuous sedative infusion is used for ongoing or refractory status epilepticus, not a single brief resolved seizure."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give a loading dose of levetiracetam for lifelong seizure prophylaxis is inappropriate because long-term antiseizure therapy is not the most appropriate immediate step when a likely reversible medication trigger is present."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous alteplase is inappropriate because alteplase is not indicated for a self-limited generalized seizure without evidence of acute ischemic stroke."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous dextrose is inappropriate because the glucose value is normal, so dextrose is unnecessary."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give a loading dose of levetiracetam for lifelong seizure prophylaxis is inappropriate because long-term antiseizure therapy is not the most appropriate immediate step when a likely reversible medication trigger is present."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start therapeutic intravenous heparin is inappropriate because there is no indication for anticoagulation based on this presentation."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous alteplase is inappropriate because alteplase is not indicated for a self-limited generalized seizure without evidence of acute ischemic stroke."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous dextrose is inappropriate because the glucose value is normal, so dextrose is unnecessary."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start therapeutic intravenous heparin is inappropriate because there is no indication for anticoagulation based on this presentation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Add intravenous calcium gluconate is inappropriate because calcium gluconate treats hyperkalemia-related membrane instability, which is not suggested here."
            },
            {
              "id": "B",
              "text": "Option A: Administer intravenous alteplase is inappropriate because alteplase is not indicated for a self-limited generalized seizure without evidence of acute ischemic stroke."
            },
            {
              "id": "C",
              "text": "Option B: Administer intravenous dextrose is inappropriate because the glucose value is normal, so dextrose is unnecessary."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Add intravenous calcium gluconate is inappropriate because calcium gluconate treats hyperkalemia-related membrane instability, which is not suggested here."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i033-acute-cholecystitis-next-procedure",
      "expectedHashes": {
        "ranaze_step3_uat": "8ece049cf2598f98c41aa1d58a848247c11ee76e04a5778030d59e2d058c4218",
        "ranaze_step3_prd": "8ece049cf2598f98c41aa1d58a848247c11ee76e04a5778030d59e2d058c4218"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Common bile duct exploration is not indicated without evidence of common bile duct stones."
            },
            {
              "id": "B",
              "text": "Option B: Endoscopic retrograde cholangiopancreatography with sphincterotomy is inappropriate because eRCP with sphincterotomy is used for suspected choledocholithiasis or cholangitis, which is not supported here."
            },
            {
              "id": "C",
              "text": "Option C: Observation only, with outpatient follow-up is inappropriate because observation alone is inappropriate for acute cholecystitis requiring definitive management."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Common bile duct exploration is not indicated without evidence of common bile duct stones."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Endoscopic retrograde cholangiopancreatography with sphincterotomy is inappropriate because eRCP with sphincterotomy is used for suspected choledocholithiasis or cholangitis, which is not supported here."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct exploration is not indicated without evidence of common bile duct stones."
            },
            {
              "id": "C",
              "text": "Option C: Observation only, with outpatient follow-up is inappropriate because observation alone is inappropriate for acute cholecystitis requiring definitive management."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Endoscopic retrograde cholangiopancreatography with sphincterotomy is inappropriate because eRCP with sphincterotomy is used for suspected choledocholithiasis or cholangitis, which is not supported here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Observation only, with outpatient follow-up is inappropriate because observation alone is inappropriate for acute cholecystitis requiring definitive management."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct exploration is not indicated without evidence of common bile duct stones."
            },
            {
              "id": "C",
              "text": "Option B: Endoscopic retrograde cholangiopancreatography with sphincterotomy is inappropriate because eRCP with sphincterotomy is used for suspected choledocholithiasis or cholangitis, which is not supported here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Observation only, with outpatient follow-up is inappropriate because observation alone is inappropriate for acute cholecystitis requiring definitive management."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Percutaneous transhepatic biliary drainage is used for biliary obstruction, not uncomplicated cystic duct obstruction in a stable patient."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct exploration is not indicated without evidence of common bile duct stones."
            },
            {
              "id": "C",
              "text": "Option B: Endoscopic retrograde cholangiopancreatography with sphincterotomy is inappropriate because eRCP with sphincterotomy is used for suspected choledocholithiasis or cholangitis, which is not supported here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Percutaneous transhepatic biliary drainage is used for biliary obstruction, not uncomplicated cystic duct obstruction in a stable patient."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Percutaneous cholecystostomy is generally reserved for patients who are unstable or poor surgical candidates."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct exploration is not indicated without evidence of common bile duct stones."
            },
            {
              "id": "C",
              "text": "Option B: Endoscopic retrograde cholangiopancreatography with sphincterotomy is inappropriate because eRCP with sphincterotomy is used for suspected choledocholithiasis or cholangitis, which is not supported here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Percutaneous cholecystostomy is generally reserved for patients who are unstable or poor surgical candidates."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ursodeoxycholic acid therapy is inappropriate because ursodeoxycholic acid is not appropriate treatment for this acute surgical condition."
            },
            {
              "id": "B",
              "text": "Option A: Common bile duct exploration is not indicated without evidence of common bile duct stones."
            },
            {
              "id": "C",
              "text": "Option B: Endoscopic retrograde cholangiopancreatography with sphincterotomy is inappropriate because eRCP with sphincterotomy is used for suspected choledocholithiasis or cholangitis, which is not supported here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ursodeoxycholic acid therapy is inappropriate because ursodeoxycholic acid is not appropriate treatment for this acute surgical condition."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i036-progressive-interstitial-lung-disease-exposure",
      "expectedHashes": {
        "ranaze_step3_uat": "89b83c0af6176e12ce44f01f2c7460c17f7aca73a1bac79245d17bd94b8f8781",
        "ranaze_step3_prd": "89b83c0af6176e12ce44f01f2c7460c17f7aca73a1bac79245d17bd94b8f8781"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recent international travel is inappropriate because recent travel does not explain calcified pleural plaques and chronic basilar interstitial fibrosis."
            },
            {
              "id": "B",
              "text": "Option C: Household rabbit exposure is inappropriate because animal exposure can be associated with hypersensitivity pneumonitis, but pleural plaques strongly point instead to asbestos exposure."
            },
            {
              "id": "C",
              "text": "Option D: Intermittent use of short-acting beta-agonist inhalers is inappropriate because intermittent beta-agonist use does not cause pleural plaques or progressive fibrotic interstitial lung disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recent international travel is inappropriate because recent travel does not explain calcified pleural plaques and chronic basilar interstitial fibrosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Household rabbit exposure is inappropriate because animal exposure can be associated with hypersensitivity pneumonitis, but pleural plaques strongly point instead to asbestos exposure."
            },
            {
              "id": "B",
              "text": "Option A: Recent international travel is inappropriate because recent travel does not explain calcified pleural plaques and chronic basilar interstitial fibrosis."
            },
            {
              "id": "C",
              "text": "Option D: Intermittent use of short-acting beta-agonist inhalers is inappropriate because intermittent beta-agonist use does not cause pleural plaques or progressive fibrotic interstitial lung disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Household rabbit exposure is inappropriate because animal exposure can be associated with hypersensitivity pneumonitis, but pleural plaques strongly point instead to asbestos exposure."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intermittent use of short-acting beta-agonist inhalers is inappropriate because intermittent beta-agonist use does not cause pleural plaques or progressive fibrotic interstitial lung disease."
            },
            {
              "id": "B",
              "text": "Option A: Recent international travel is inappropriate because recent travel does not explain calcified pleural plaques and chronic basilar interstitial fibrosis."
            },
            {
              "id": "C",
              "text": "Option C: Household rabbit exposure is inappropriate because animal exposure can be associated with hypersensitivity pneumonitis, but pleural plaques strongly point instead to asbestos exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intermittent use of short-acting beta-agonist inhalers is inappropriate because intermittent beta-agonist use does not cause pleural plaques or progressive fibrotic interstitial lung disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Undiagnosed pulmonary emboli is inappropriate because pulmonary emboli can cause dyspnea, but they do not cause calcified pleural plaques or this chronic fibrotic pattern."
            },
            {
              "id": "B",
              "text": "Option A: Recent international travel is inappropriate because recent travel does not explain calcified pleural plaques and chronic basilar interstitial fibrosis."
            },
            {
              "id": "C",
              "text": "Option C: Household rabbit exposure is inappropriate because animal exposure can be associated with hypersensitivity pneumonitis, but pleural plaques strongly point instead to asbestos exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Undiagnosed pulmonary emboli is inappropriate because pulmonary emboli can cause dyspnea, but they do not cause calcified pleural plaques or this chronic fibrotic pattern."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Community hot tub use is inappropriate because hot tub exposure is associated with hypersensitivity pneumonitis-like illness or atypical infection, not pleural plaques from mineral fiber exposure."
            },
            {
              "id": "B",
              "text": "Option A: Recent international travel is inappropriate because recent travel does not explain calcified pleural plaques and chronic basilar interstitial fibrosis."
            },
            {
              "id": "C",
              "text": "Option C: Household rabbit exposure is inappropriate because animal exposure can be associated with hypersensitivity pneumonitis, but pleural plaques strongly point instead to asbestos exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Community hot tub use is inappropriate because hot tub exposure is associated with hypersensitivity pneumonitis-like illness or atypical infection, not pleural plaques from mineral fiber exposure."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Secondhand tobacco smoke exposure is inappropriate because secondhand smoke is not the classic association for pleural plaques and asbestos-related pulmonary fibrosis."
            },
            {
              "id": "B",
              "text": "Option A: Recent international travel is inappropriate because recent travel does not explain calcified pleural plaques and chronic basilar interstitial fibrosis."
            },
            {
              "id": "C",
              "text": "Option C: Household rabbit exposure is inappropriate because animal exposure can be associated with hypersensitivity pneumonitis, but pleural plaques strongly point instead to asbestos exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Secondhand tobacco smoke exposure is inappropriate because secondhand smoke is not the classic association for pleural plaques and asbestos-related pulmonary fibrosis."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i037-congenital-cmv-long-term-sequela",
      "expectedHashes": {
        "ranaze_step3_uat": "5ddb0e775fd99f7368172db3d99f804743f6ca93b710d1f650e7ece461042daa",
        "ranaze_step3_prd": "5ddb0e775fd99f7368172db3d99f804743f6ca93b710d1f650e7ece461042daa"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neonatal hepatitis can occur, but progressive liver failure is not the characteristic long-term sequela being tested here."
            },
            {
              "id": "B",
              "text": "Option C: Congenital cataracts is inappropriate because cataracts are classically associated with congenital rubella, not congenital cytomegalovirus with periventricular calcifications."
            },
            {
              "id": "C",
              "text": "Option D: Acute leukemia in childhood is inappropriate because congenital cytomegalovirus is not a classic cause of childhood acute leukemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neonatal hepatitis can occur, but progressive liver failure is not the characteristic long-term sequela being tested here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Congenital cataracts is inappropriate because cataracts are classically associated with congenital rubella, not congenital cytomegalovirus with periventricular calcifications."
            },
            {
              "id": "B",
              "text": "Option B: Neonatal hepatitis can occur, but progressive liver failure is not the characteristic long-term sequela being tested here."
            },
            {
              "id": "C",
              "text": "Option D: Acute leukemia in childhood is inappropriate because congenital cytomegalovirus is not a classic cause of childhood acute leukemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Congenital cataracts is inappropriate because cataracts are classically associated with congenital rubella, not congenital cytomegalovirus with periventricular calcifications."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute leukemia in childhood is inappropriate because congenital cytomegalovirus is not a classic cause of childhood acute leukemia."
            },
            {
              "id": "B",
              "text": "Option B: Neonatal hepatitis can occur, but progressive liver failure is not the characteristic long-term sequela being tested here."
            },
            {
              "id": "C",
              "text": "Option C: Congenital cataracts is inappropriate because cataracts are classically associated with congenital rubella, not congenital cytomegalovirus with periventricular calcifications."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute leukemia in childhood is inappropriate because congenital cytomegalovirus is not a classic cause of childhood acute leukemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obstructive hydrocephalus from aqueductal stenosis is inappropriate because hydrocephalus is more classically associated with congenital toxoplasmosis; this stem instead features periventricular calcifications typical of congenital cytomegalovirus."
            },
            {
              "id": "B",
              "text": "Option B: Neonatal hepatitis can occur, but progressive liver failure is not the characteristic long-term sequela being tested here."
            },
            {
              "id": "C",
              "text": "Option C: Congenital cataracts is inappropriate because cataracts are classically associated with congenital rubella, not congenital cytomegalovirus with periventricular calcifications."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obstructive hydrocephalus from aqueductal stenosis is inappropriate because hydrocephalus is more classically associated with congenital toxoplasmosis; this stem instead features periventricular calcifications typical of congenital cytomegalovirus."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Coarctation of the aorta is inappropriate because coarctation is not a characteristic sequela of congenital cytomegalovirus infection."
            },
            {
              "id": "B",
              "text": "Option B: Neonatal hepatitis can occur, but progressive liver failure is not the characteristic long-term sequela being tested here."
            },
            {
              "id": "C",
              "text": "Option C: Congenital cataracts is inappropriate because cataracts are classically associated with congenital rubella, not congenital cytomegalovirus with periventricular calcifications."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Coarctation of the aorta is inappropriate because coarctation is not a characteristic sequela of congenital cytomegalovirus infection."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recurrent bacterial meningitis is not a typical long-term sequela of congenital cytomegalovirus."
            },
            {
              "id": "B",
              "text": "Option B: Neonatal hepatitis can occur, but progressive liver failure is not the characteristic long-term sequela being tested here."
            },
            {
              "id": "C",
              "text": "Option C: Congenital cataracts is inappropriate because cataracts are classically associated with congenital rubella, not congenital cytomegalovirus with periventricular calcifications."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recurrent bacterial meningitis is not a typical long-term sequela of congenital cytomegalovirus."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i038-painful-diabetic-neuropathy-treatment",
      "expectedHashes": {
        "ranaze_step3_uat": "3a92264ceaadc234bb12bf9fc6fe6b187795dede7e247d00fe00fec2f7beb828",
        "ranaze_step3_prd": "3a92264ceaadc234bb12bf9fc6fe6b187795dede7e247d00fe00fec2f7beb828"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amitriptyline can help neuropathic pain, but its anticholinergic effects are a poor fit for a patient with benign prostatic hyperplasia and nocturia, and it can also impair alertness."
            },
            {
              "id": "B",
              "text": "Option C: Gabapentin can treat neuropathic pain, but sedation is a drawback in a patient who drives a school bus and needs to stay alert for work."
            },
            {
              "id": "C",
              "text": "Option D: Pregabalin is another option for neuropathic pain, but sedation and dizziness make it less attractive for someone who must remain alert while driving."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amitriptyline can help neuropathic pain, but its anticholinergic effects are a poor fit for a patient with benign prostatic hyperplasia and nocturia, and it can also impair alertness."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gabapentin can treat neuropathic pain, but sedation is a drawback in a patient who drives a school bus and needs to stay alert for work."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can help neuropathic pain, but its anticholinergic effects are a poor fit for a patient with benign prostatic hyperplasia and nocturia, and it can also impair alertness."
            },
            {
              "id": "C",
              "text": "Option D: Pregabalin is another option for neuropathic pain, but sedation and dizziness make it less attractive for someone who must remain alert while driving."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gabapentin can treat neuropathic pain, but sedation is a drawback in a patient who drives a school bus and needs to stay alert for work."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pregabalin is another option for neuropathic pain, but sedation and dizziness make it less attractive for someone who must remain alert while driving."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can help neuropathic pain, but its anticholinergic effects are a poor fit for a patient with benign prostatic hyperplasia and nocturia, and it can also impair alertness."
            },
            {
              "id": "C",
              "text": "Option C: Gabapentin can treat neuropathic pain, but sedation is a drawback in a patient who drives a school bus and needs to stay alert for work."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pregabalin is another option for neuropathic pain, but sedation and dizziness make it less attractive for someone who must remain alert while driving."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lidocaine 5% patches is inappropriate because lidocaine patches are less suitable for diffuse bilateral stocking-distribution symptoms extending to the mid-calves."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can help neuropathic pain, but its anticholinergic effects are a poor fit for a patient with benign prostatic hyperplasia and nocturia, and it can also impair alertness."
            },
            {
              "id": "C",
              "text": "Option C: Gabapentin can treat neuropathic pain, but sedation is a drawback in a patient who drives a school bus and needs to stay alert for work."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lidocaine 5% patches is inappropriate because lidocaine patches are less suitable for diffuse bilateral stocking-distribution symptoms extending to the mid-calves."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Extended-release oxycodone is inappropriate because long-term opioid therapy is not an appropriate next step for chronic painful diabetic neuropathy when effective nonopioid treatments are available."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can help neuropathic pain, but its anticholinergic effects are a poor fit for a patient with benign prostatic hyperplasia and nocturia, and it can also impair alertness."
            },
            {
              "id": "C",
              "text": "Option C: Gabapentin can treat neuropathic pain, but sedation is a drawback in a patient who drives a school bus and needs to stay alert for work."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Extended-release oxycodone is inappropriate because long-term opioid therapy is not an appropriate next step for chronic painful diabetic neuropathy when effective nonopioid treatments are available."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Venlafaxine can help some neuropathic pain syndromes, but duloxetine has stronger established use for painful diabetic peripheral neuropathy and better fits this patient\u0027s full presentation."
            },
            {
              "id": "B",
              "text": "Option A: Amitriptyline can help neuropathic pain, but its anticholinergic effects are a poor fit for a patient with benign prostatic hyperplasia and nocturia, and it can also impair alertness."
            },
            {
              "id": "C",
              "text": "Option C: Gabapentin can treat neuropathic pain, but sedation is a drawback in a patient who drives a school bus and needs to stay alert for work."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Venlafaxine can help some neuropathic pain syndromes, but duloxetine has stronger established use for painful diabetic peripheral neuropathy and better fits this patient\u0027s full presentation."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i039-tachyarrhythmia-symptom-mechanism",
      "expectedHashes": {
        "ranaze_step3_uat": "a484f8dd135c981822a4a7c1676a4fb8b6da88c554415630647cc0e0e4ee870f",
        "ranaze_step3_prd": "a484f8dd135c981822a4a7c1676a4fb8b6da88c554415630647cc0e0e4ee870f"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute obstruction of an epicardial coronary artery is inappropriate because there is no evidence of acute coronary occlusion; the abrupt regular tachyarrhythmia better explains the symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Increased myocardial wall stress from severe hypertension is inappropriate because his blood pressure is not severely elevated, so hypertensive wall stress is not the best explanation."
            },
            {
              "id": "C",
              "text": "Option D: A sudden fall in arterial oxygen content is inappropriate because oxygen saturation is normal, so reduced arterial oxygen content is not the mechanism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute obstruction of an epicardial coronary artery is inappropriate because there is no evidence of acute coronary occlusion; the abrupt regular tachyarrhythmia better explains the symptoms."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased myocardial wall stress from severe hypertension is inappropriate because his blood pressure is not severely elevated, so hypertensive wall stress is not the best explanation."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of an epicardial coronary artery is inappropriate because there is no evidence of acute coronary occlusion; the abrupt regular tachyarrhythmia better explains the symptoms."
            },
            {
              "id": "C",
              "text": "Option D: A sudden fall in arterial oxygen content is inappropriate because oxygen saturation is normal, so reduced arterial oxygen content is not the mechanism."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased myocardial wall stress from severe hypertension is inappropriate because his blood pressure is not severely elevated, so hypertensive wall stress is not the best explanation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A sudden fall in arterial oxygen content is inappropriate because oxygen saturation is normal, so reduced arterial oxygen content is not the mechanism."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of an epicardial coronary artery is inappropriate because there is no evidence of acute coronary occlusion; the abrupt regular tachyarrhythmia better explains the symptoms."
            },
            {
              "id": "C",
              "text": "Option B: Increased myocardial wall stress from severe hypertension is inappropriate because his blood pressure is not severely elevated, so hypertensive wall stress is not the best explanation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A sudden fall in arterial oxygen content is inappropriate because oxygen saturation is normal, so reduced arterial oxygen content is not the mechanism."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An abrupt rise in left ventricular afterload from aortic stenosis is inappropriate because nothing in the stem suggests fixed valvular outflow obstruction, and that would not explain the sudden regular narrow-complex tachycardia."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of an epicardial coronary artery is inappropriate because there is no evidence of acute coronary occlusion; the abrupt regular tachyarrhythmia better explains the symptoms."
            },
            {
              "id": "C",
              "text": "Option B: Increased myocardial wall stress from severe hypertension is inappropriate because his blood pressure is not severely elevated, so hypertensive wall stress is not the best explanation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An abrupt rise in left ventricular afterload from aortic stenosis is inappropriate because nothing in the stem suggests fixed valvular outflow obstruction, and that would not explain the sudden regular narrow-complex tachycardia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inflammation of the pericardium causing pain with tachycardia is inappropriate because pericarditis causes pleuritic chest pain, not this abrupt tachyarrhythmia-related presyncope pattern."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of an epicardial coronary artery is inappropriate because there is no evidence of acute coronary occlusion; the abrupt regular tachyarrhythmia better explains the symptoms."
            },
            {
              "id": "C",
              "text": "Option B: Increased myocardial wall stress from severe hypertension is inappropriate because his blood pressure is not severely elevated, so hypertensive wall stress is not the best explanation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inflammation of the pericardium causing pain with tachycardia is inappropriate because pericarditis causes pleuritic chest pain, not this abrupt tachyarrhythmia-related presyncope pattern."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Loss of atrial contraction from complete heart block is inappropriate because complete heart block causes bradyarrhythmia rather than a regular narrow-complex tachycardia at 188/min."
            },
            {
              "id": "B",
              "text": "Option A: Acute obstruction of an epicardial coronary artery is inappropriate because there is no evidence of acute coronary occlusion; the abrupt regular tachyarrhythmia better explains the symptoms."
            },
            {
              "id": "C",
              "text": "Option B: Increased myocardial wall stress from severe hypertension is inappropriate because his blood pressure is not severely elevated, so hypertensive wall stress is not the best explanation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Loss of atrial contraction from complete heart block is inappropriate because complete heart block causes bradyarrhythmia rather than a regular narrow-complex tachycardia at 188/min."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i040-address-social-barriers-to-treatment",
      "expectedHashes": {
        "ranaze_step3_uat": "6f424396afda4fd2b77277de02a48c967ec8d3d1c0381c507a163cc1dfc9694d",
        "ranaze_step3_prd": "6f424396afda4fd2b77277de02a48c967ec8d3d1c0381c507a163cc1dfc9694d"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Admit her for intravenous antibiotics is inappropriate because she has no fever, purulent drainage, or spreading erythema to suggest a severe infection requiring hospital admission and intravenous antibiotics."
            },
            {
              "id": "B",
              "text": "Option B: Increase her diuretic dose to reduce leg swelling is inappropriate because increasing a diuretic does not address the stated reasons she cannot follow the wound-care plan."
            },
            {
              "id": "C",
              "text": "Option C: Provide a detailed handout emphasizing strict compression and leg elevation is inappropriate because she already faces practical barriers to compression and elevation; more instructions alone do not solve unstable housing, transportation, and cost problems."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Admit her for intravenous antibiotics is inappropriate because she has no fever, purulent drainage, or spreading erythema to suggest a severe infection requiring hospital admission and intravenous antibiotics."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase her diuretic dose to reduce leg swelling is inappropriate because increasing a diuretic does not address the stated reasons she cannot follow the wound-care plan."
            },
            {
              "id": "B",
              "text": "Option A: Admit her for intravenous antibiotics is inappropriate because she has no fever, purulent drainage, or spreading erythema to suggest a severe infection requiring hospital admission and intravenous antibiotics."
            },
            {
              "id": "C",
              "text": "Option C: Provide a detailed handout emphasizing strict compression and leg elevation is inappropriate because she already faces practical barriers to compression and elevation; more instructions alone do not solve unstable housing, transportation, and cost problems."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase her diuretic dose to reduce leg swelling is inappropriate because increasing a diuretic does not address the stated reasons she cannot follow the wound-care plan."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide a detailed handout emphasizing strict compression and leg elevation is inappropriate because she already faces practical barriers to compression and elevation; more instructions alone do not solve unstable housing, transportation, and cost problems."
            },
            {
              "id": "B",
              "text": "Option A: Admit her for intravenous antibiotics is inappropriate because she has no fever, purulent drainage, or spreading erythema to suggest a severe infection requiring hospital admission and intravenous antibiotics."
            },
            {
              "id": "C",
              "text": "Option B: Increase her diuretic dose to reduce leg swelling is inappropriate because increasing a diuretic does not address the stated reasons she cannot follow the wound-care plan."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide a detailed handout emphasizing strict compression and leg elevation is inappropriate because she already faces practical barriers to compression and elevation; more instructions alone do not solve unstable housing, transportation, and cost problems."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give several dressing kits from the office and ask her to return when she is able is inappropriate because a few dressing kits may help briefly, but this does not adequately address the ongoing barriers that are driving treatment failure."
            },
            {
              "id": "B",
              "text": "Option A: Admit her for intravenous antibiotics is inappropriate because she has no fever, purulent drainage, or spreading erythema to suggest a severe infection requiring hospital admission and intravenous antibiotics."
            },
            {
              "id": "C",
              "text": "Option B: Increase her diuretic dose to reduce leg swelling is inappropriate because increasing a diuretic does not address the stated reasons she cannot follow the wound-care plan."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give several dressing kits from the office and ask her to return when she is able is inappropriate because a few dressing kits may help briefly, but this does not adequately address the ongoing barriers that are driving treatment failure."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer her to a different wound clinic with lower out-of-pocket costs is inappropriate because a referral alone does not solve the transportation, housing, and supply barriers described in the stem."
            },
            {
              "id": "B",
              "text": "Option A: Admit her for intravenous antibiotics is inappropriate because she has no fever, purulent drainage, or spreading erythema to suggest a severe infection requiring hospital admission and intravenous antibiotics."
            },
            {
              "id": "C",
              "text": "Option B: Increase her diuretic dose to reduce leg swelling is inappropriate because increasing a diuretic does not address the stated reasons she cannot follow the wound-care plan."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer her to a different wound clinic with lower out-of-pocket costs is inappropriate because a referral alone does not solve the transportation, housing, and supply barriers described in the stem."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tell her to stop working until the ulcer heals is inappropriate because simply telling her to stop working is unrealistic and does not connect her with resources to make the plan feasible."
            },
            {
              "id": "B",
              "text": "Option A: Admit her for intravenous antibiotics is inappropriate because she has no fever, purulent drainage, or spreading erythema to suggest a severe infection requiring hospital admission and intravenous antibiotics."
            },
            {
              "id": "C",
              "text": "Option B: Increase her diuretic dose to reduce leg swelling is inappropriate because increasing a diuretic does not address the stated reasons she cannot follow the wound-care plan."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tell her to stop working until the ulcer heals is inappropriate because simply telling her to stop working is unrealistic and does not connect her with resources to make the plan feasible."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i041-interpret-subgroup-hazard-ratios",
      "expectedHashes": {
        "ranaze_step3_uat": "63781679b1c0800490dbf46873d0c619a62a889051e6ad028a76e173dd0ae236",
        "ranaze_step3_prd": "63781679b1c0800490dbf46873d0c619a62a889051e6ad028a76e173dd0ae236"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because readmission is not clearly improved because the confidence interval for 0.93 spans 1, and mortality does show benefit because its confidence interval stays below 1."
            },
            {
              "id": "B",
              "text": "Option C: No benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because time to clinical stability does show benefit because 0.70 with a 95% confidence interval of 0.60 to 0.82 is entirely below 1."
            },
            {
              "id": "C",
              "text": "Option D: No benefit for time to clinical stability, no benefit for readmission, benefit for mortality is inappropriate because time to clinical stability does show benefit, and readmission does not because its confidence interval includes 1."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because readmission is not clearly improved because the confidence interval for 0.93 spans 1, and mortality does show benefit because its confidence interval stays below 1."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because time to clinical stability does show benefit because 0.70 with a 95% confidence interval of 0.60 to 0.82 is entirely below 1."
            },
            {
              "id": "B",
              "text": "Option B: Benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because readmission is not clearly improved because the confidence interval for 0.93 spans 1, and mortality does show benefit because its confidence interval stays below 1."
            },
            {
              "id": "C",
              "text": "Option D: No benefit for time to clinical stability, no benefit for readmission, benefit for mortality is inappropriate because time to clinical stability does show benefit, and readmission does not because its confidence interval includes 1."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because time to clinical stability does show benefit because 0.70 with a 95% confidence interval of 0.60 to 0.82 is entirely below 1."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No benefit for time to clinical stability, no benefit for readmission, benefit for mortality is inappropriate because time to clinical stability does show benefit, and readmission does not because its confidence interval includes 1."
            },
            {
              "id": "B",
              "text": "Option B: Benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because readmission is not clearly improved because the confidence interval for 0.93 spans 1, and mortality does show benefit because its confidence interval stays below 1."
            },
            {
              "id": "C",
              "text": "Option C: No benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because time to clinical stability does show benefit because 0.70 with a 95% confidence interval of 0.60 to 0.82 is entirely below 1."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No benefit for time to clinical stability, no benefit for readmission, benefit for mortality is inappropriate because time to clinical stability does show benefit, and readmission does not because its confidence interval includes 1."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Benefit for time to clinical stability, no benefit for readmission, no benefit for mortality is inappropriate because mortality does show benefit because 0.84 with a 95% confidence interval of 0.73 to 0.97 is entirely below 1."
            },
            {
              "id": "B",
              "text": "Option B: Benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because readmission is not clearly improved because the confidence interval for 0.93 spans 1, and mortality does show benefit because its confidence interval stays below 1."
            },
            {
              "id": "C",
              "text": "Option C: No benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because time to clinical stability does show benefit because 0.70 with a 95% confidence interval of 0.60 to 0.82 is entirely below 1."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Benefit for time to clinical stability, no benefit for readmission, no benefit for mortality is inappropriate because mortality does show benefit because 0.84 with a 95% confidence interval of 0.73 to 0.97 is entirely below 1."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No benefit for time to clinical stability, no benefit for readmission, no benefit for mortality is inappropriate because this choice ignores the two outcomes whose confidence intervals are entirely below 1."
            },
            {
              "id": "B",
              "text": "Option B: Benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because readmission is not clearly improved because the confidence interval for 0.93 spans 1, and mortality does show benefit because its confidence interval stays below 1."
            },
            {
              "id": "C",
              "text": "Option C: No benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because time to clinical stability does show benefit because 0.70 with a 95% confidence interval of 0.60 to 0.82 is entirely below 1."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No benefit for time to clinical stability, no benefit for readmission, no benefit for mortality is inappropriate because this choice ignores the two outcomes whose confidence intervals are entirely below 1."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Benefit for time to clinical stability, benefit for readmission, benefit for mortality is inappropriate because readmission cannot be called beneficial here because the confidence interval for that hazard ratio includes 1."
            },
            {
              "id": "B",
              "text": "Option B: Benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because readmission is not clearly improved because the confidence interval for 0.93 spans 1, and mortality does show benefit because its confidence interval stays below 1."
            },
            {
              "id": "C",
              "text": "Option C: No benefit for time to clinical stability, benefit for readmission, no benefit for mortality is inappropriate because time to clinical stability does show benefit because 0.70 with a 95% confidence interval of 0.60 to 0.82 is entirely below 1."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Benefit for time to clinical stability, benefit for readmission, benefit for mortality is inappropriate because readmission cannot be called beneficial here because the confidence interval for that hazard ratio includes 1."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i042-name-and-validate-emotion",
      "expectedHashes": {
        "ranaze_step3_uat": "98ca56eff2e4f3b58dc22695e62254a64230613d1427967217ddedb6cdb95b72",
        "ranaze_step3_prd": "98ca56eff2e4f3b58dc22695e62254a64230613d1427967217ddedb6cdb95b72"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022What additional tests were you hoping I would order today?\u0022 is inappropriate because jumping immediately to test ordering preference bypasses the patient\u0027s expressed frustration and sense of being disbelieved."
            },
            {
              "id": "B",
              "text": "Option B: \u0022Lots of people are stressed after COVID, so try not to focus on the symptoms.\u0022 is inappropriate because minimizing the symptoms and attributing them to stress undermines rapport."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Tell me why you think the other physicians could not help you.\u0022 is inappropriate because asking why prior clinicians failed is premature and can sound adversarial rather than empathic."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022What additional tests were you hoping I would order today?\u0022 is inappropriate because jumping immediately to test ordering preference bypasses the patient\u0027s expressed frustration and sense of being disbelieved."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Lots of people are stressed after COVID, so try not to focus on the symptoms.\u0022 is inappropriate because minimizing the symptoms and attributing them to stress undermines rapport."
            },
            {
              "id": "B",
              "text": "Option A: \u0022What additional tests were you hoping I would order today?\u0022 is inappropriate because jumping immediately to test ordering preference bypasses the patient\u0027s expressed frustration and sense of being disbelieved."
            },
            {
              "id": "C",
              "text": "Option C: \u0022Tell me why you think the other physicians could not help you.\u0022 is inappropriate because asking why prior clinicians failed is premature and can sound adversarial rather than empathic."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Lots of people are stressed after COVID, so try not to focus on the symptoms.\u0022 is inappropriate because minimizing the symptoms and attributing them to stress undermines rapport."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Tell me why you think the other physicians could not help you.\u0022 is inappropriate because asking why prior clinicians failed is premature and can sound adversarial rather than empathic."
            },
            {
              "id": "B",
              "text": "Option A: \u0022What additional tests were you hoping I would order today?\u0022 is inappropriate because jumping immediately to test ordering preference bypasses the patient\u0027s expressed frustration and sense of being disbelieved."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Lots of people are stressed after COVID, so try not to focus on the symptoms.\u0022 is inappropriate because minimizing the symptoms and attributing them to stress undermines rapport."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Tell me why you think the other physicians could not help you.\u0022 is inappropriate because asking why prior clinicians failed is premature and can sound adversarial rather than empathic."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022I had a relative with something similar, and he eventually improved.\u0022 is inappropriate because self-disclosure shifts attention away from the patient and does not first address his emotion."
            },
            {
              "id": "B",
              "text": "Option A: \u0022What additional tests were you hoping I would order today?\u0022 is inappropriate because jumping immediately to test ordering preference bypasses the patient\u0027s expressed frustration and sense of being disbelieved."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Lots of people are stressed after COVID, so try not to focus on the symptoms.\u0022 is inappropriate because minimizing the symptoms and attributing them to stress undermines rapport."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022I had a relative with something similar, and he eventually improved.\u0022 is inappropriate because self-disclosure shifts attention away from the patient and does not first address his emotion."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Since your prior testing was normal, we can be reassured this is nothing dangerous.\u0022 is inappropriate because premature reassurance after the patient says he feels disbelieved is counterproductive."
            },
            {
              "id": "B",
              "text": "Option A: \u0022What additional tests were you hoping I would order today?\u0022 is inappropriate because jumping immediately to test ordering preference bypasses the patient\u0027s expressed frustration and sense of being disbelieved."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Lots of people are stressed after COVID, so try not to focus on the symptoms.\u0022 is inappropriate because minimizing the symptoms and attributing them to stress undermines rapport."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Since your prior testing was normal, we can be reassured this is nothing dangerous.\u0022 is inappropriate because premature reassurance after the patient says he feels disbelieved is counterproductive."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "\u0022Do you have any questions for me before we begin?\u0022 is inappropriate because a generic opening question misses the explicit emotional cue that should be addressed first."
            },
            {
              "id": "B",
              "text": "Option A: \u0022What additional tests were you hoping I would order today?\u0022 is inappropriate because jumping immediately to test ordering preference bypasses the patient\u0027s expressed frustration and sense of being disbelieved."
            },
            {
              "id": "C",
              "text": "Option B: \u0022Lots of people are stressed after COVID, so try not to focus on the symptoms.\u0022 is inappropriate because minimizing the symptoms and attributing them to stress undermines rapport."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "\u0022Do you have any questions for me before we begin?\u0022 is inappropriate because a generic opening question misses the explicit emotional cue that should be addressed first."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i043-identify-pill-esophagitis",
      "expectedHashes": {
        "ranaze_step3_uat": "5c508c019e5609a8176ffc2f523bd7e729a798bbc0941476af93b0af2b46f0f9",
        "ranaze_step3_prd": "5c508c019e5609a8176ffc2f523bd7e729a798bbc0941476af93b0af2b46f0f9"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diffuse esophageal spasm causes intermittent chest pain or dysphagia, not an acute medication-timed odynophagia syndrome after taking a capsule at bedtime."
            },
            {
              "id": "B",
              "text": "Option B: Eosinophilic esophagitis usually causes chronic solid-food dysphagia or impaction, often in patients with atopy, rather than abrupt symptoms after a specific pill exposure."
            },
            {
              "id": "C",
              "text": "Option C: Esophageal adenocarcinoma is unlikely in a young patient with an abrupt 2-day course linked to pill ingestion and no progressive dysphagia or weight loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diffuse esophageal spasm causes intermittent chest pain or dysphagia, not an acute medication-timed odynophagia syndrome after taking a capsule at bedtime."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Eosinophilic esophagitis usually causes chronic solid-food dysphagia or impaction, often in patients with atopy, rather than abrupt symptoms after a specific pill exposure."
            },
            {
              "id": "B",
              "text": "Option A: Diffuse esophageal spasm causes intermittent chest pain or dysphagia, not an acute medication-timed odynophagia syndrome after taking a capsule at bedtime."
            },
            {
              "id": "C",
              "text": "Option C: Esophageal adenocarcinoma is unlikely in a young patient with an abrupt 2-day course linked to pill ingestion and no progressive dysphagia or weight loss."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Eosinophilic esophagitis usually causes chronic solid-food dysphagia or impaction, often in patients with atopy, rather than abrupt symptoms after a specific pill exposure."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Esophageal adenocarcinoma is unlikely in a young patient with an abrupt 2-day course linked to pill ingestion and no progressive dysphagia or weight loss."
            },
            {
              "id": "B",
              "text": "Option A: Diffuse esophageal spasm causes intermittent chest pain or dysphagia, not an acute medication-timed odynophagia syndrome after taking a capsule at bedtime."
            },
            {
              "id": "C",
              "text": "Option B: Eosinophilic esophagitis usually causes chronic solid-food dysphagia or impaction, often in patients with atopy, rather than abrupt symptoms after a specific pill exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Esophageal adenocarcinoma is unlikely in a young patient with an abrupt 2-day course linked to pill ingestion and no progressive dysphagia or weight loss."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gastroesophageal reflux disease is inappropriate because gERD can cause heartburn and sometimes odynophagia, but the timing with doxycycline taken with little water before lying down strongly favors pill injury."
            },
            {
              "id": "B",
              "text": "Option A: Diffuse esophageal spasm causes intermittent chest pain or dysphagia, not an acute medication-timed odynophagia syndrome after taking a capsule at bedtime."
            },
            {
              "id": "C",
              "text": "Option B: Eosinophilic esophagitis usually causes chronic solid-food dysphagia or impaction, often in patients with atopy, rather than abrupt symptoms after a specific pill exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gastroesophageal reflux disease is inappropriate because gERD can cause heartburn and sometimes odynophagia, but the timing with doxycycline taken with little water before lying down strongly favors pill injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Infectious esophagitis is more likely in immunocompromised patients and does not fit the clear precipitating medication history."
            },
            {
              "id": "B",
              "text": "Option A: Diffuse esophageal spasm causes intermittent chest pain or dysphagia, not an acute medication-timed odynophagia syndrome after taking a capsule at bedtime."
            },
            {
              "id": "C",
              "text": "Option B: Eosinophilic esophagitis usually causes chronic solid-food dysphagia or impaction, often in patients with atopy, rather than abrupt symptoms after a specific pill exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Infectious esophagitis is more likely in immunocompromised patients and does not fit the clear precipitating medication history."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Zenker diverticulum causes chronic oropharyngeal dysphagia, regurgitation, and halitosis, not sudden painful swallowing after one medication dose."
            },
            {
              "id": "B",
              "text": "Option A: Diffuse esophageal spasm causes intermittent chest pain or dysphagia, not an acute medication-timed odynophagia syndrome after taking a capsule at bedtime."
            },
            {
              "id": "C",
              "text": "Option B: Eosinophilic esophagitis usually causes chronic solid-food dysphagia or impaction, often in patients with atopy, rather than abrupt symptoms after a specific pill exposure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Zenker diverticulum causes chronic oropharyngeal dysphagia, regurgitation, and halitosis, not sudden painful swallowing after one medication dose."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i045-adhd-initial-standardized-assessment",
      "expectedHashes": {
        "ranaze_step3_uat": "3abd8e72ff7b2c19ec58ac3203b19dc8e8e740329bbfde8cd9adaa97ded3d2b4",
        "ranaze_step3_prd": "3abd8e72ff7b2c19ec58ac3203b19dc8e8e740329bbfde8cd9adaa97ded3d2b4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin extended-release methylphenidate therapy is inappropriate because medication can be appropriate after the diagnostic assessment is completed, but treatment should not be started before obtaining the structured information needed to establish the diagnosis."
            },
            {
              "id": "B",
              "text": "Option C: Arrange psychoeducational testing for a specific learning disorder is inappropriate because specific learning disorder testing is useful when there is isolated academic skill impairment, but this child has broadly age-appropriate academics and prominent behavioral symptoms across settings."
            },
            {
              "id": "C",
              "text": "Option D: Order an electroencephalogram is inappropriate because absence seizures cause brief unresponsive episodes that are not terminated by redirection; her episodes stop when her name is called and fit inattention better than seizures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin extended-release methylphenidate therapy is inappropriate because medication can be appropriate after the diagnostic assessment is completed, but treatment should not be started before obtaining the structured information needed to establish the diagnosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arrange psychoeducational testing for a specific learning disorder is inappropriate because specific learning disorder testing is useful when there is isolated academic skill impairment, but this child has broadly age-appropriate academics and prominent behavioral symptoms across settings."
            },
            {
              "id": "B",
              "text": "Option B: Begin extended-release methylphenidate therapy is inappropriate because medication can be appropriate after the diagnostic assessment is completed, but treatment should not be started before obtaining the structured information needed to establish the diagnosis."
            },
            {
              "id": "C",
              "text": "Option D: Order an electroencephalogram is inappropriate because absence seizures cause brief unresponsive episodes that are not terminated by redirection; her episodes stop when her name is called and fit inattention better than seizures."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arrange psychoeducational testing for a specific learning disorder is inappropriate because specific learning disorder testing is useful when there is isolated academic skill impairment, but this child has broadly age-appropriate academics and prominent behavioral symptoms across settings."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order an electroencephalogram is inappropriate because absence seizures cause brief unresponsive episodes that are not terminated by redirection; her episodes stop when her name is called and fit inattention better than seizures."
            },
            {
              "id": "B",
              "text": "Option B: Begin extended-release methylphenidate therapy is inappropriate because medication can be appropriate after the diagnostic assessment is completed, but treatment should not be started before obtaining the structured information needed to establish the diagnosis."
            },
            {
              "id": "C",
              "text": "Option C: Arrange psychoeducational testing for a specific learning disorder is inappropriate because specific learning disorder testing is useful when there is isolated academic skill impairment, but this child has broadly age-appropriate academics and prominent behavioral symptoms across settings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order an electroencephalogram is inappropriate because absence seizures cause brief unresponsive episodes that are not terminated by redirection; her episodes stop when her name is called and fit inattention better than seizures."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend parent-management training as the only intervention is inappropriate because parent-management training can help as an adjunct, but using it alone is not the best next step before the diagnostic evaluation is completed."
            },
            {
              "id": "B",
              "text": "Option B: Begin extended-release methylphenidate therapy is inappropriate because medication can be appropriate after the diagnostic assessment is completed, but treatment should not be started before obtaining the structured information needed to establish the diagnosis."
            },
            {
              "id": "C",
              "text": "Option C: Arrange psychoeducational testing for a specific learning disorder is inappropriate because specific learning disorder testing is useful when there is isolated academic skill impairment, but this child has broadly age-appropriate academics and prominent behavioral symptoms across settings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend parent-management training as the only intervention is inappropriate because parent-management training can help as an adjunct, but using it alone is not the best next step before the diagnostic evaluation is completed."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassure the family that this behavior is typical for her age is inappropriate because the behavior is causing impairment at home and school over many months, so reassurance alone is inappropriate."
            },
            {
              "id": "B",
              "text": "Option B: Begin extended-release methylphenidate therapy is inappropriate because medication can be appropriate after the diagnostic assessment is completed, but treatment should not be started before obtaining the structured information needed to establish the diagnosis."
            },
            {
              "id": "C",
              "text": "Option C: Arrange psychoeducational testing for a specific learning disorder is inappropriate because specific learning disorder testing is useful when there is isolated academic skill impairment, but this child has broadly age-appropriate academics and prominent behavioral symptoms across settings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassure the family that this behavior is typical for her age is inappropriate because the behavior is causing impairment at home and school over many months, so reassurance alone is inappropriate."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order thyroid-stimulating hormone and complete blood count testing is inappropriate because routine laboratory screening is not the next step when the history and examination do not suggest a medical cause of inattention or hyperactivity."
            },
            {
              "id": "B",
              "text": "Option B: Begin extended-release methylphenidate therapy is inappropriate because medication can be appropriate after the diagnostic assessment is completed, but treatment should not be started before obtaining the structured information needed to establish the diagnosis."
            },
            {
              "id": "C",
              "text": "Option C: Arrange psychoeducational testing for a specific learning disorder is inappropriate because specific learning disorder testing is useful when there is isolated academic skill impairment, but this child has broadly age-appropriate academics and prominent behavioral symptoms across settings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order thyroid-stimulating hormone and complete blood count testing is inappropriate because routine laboratory screening is not the next step when the history and examination do not suggest a medical cause of inattention or hyperactivity."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i046-statin-myalgia-check-ck",
      "expectedHashes": {
        "ranaze_step3_uat": "780e2f555fad6a59d12f43e7c423b03fe2132c488adc8f9bfed9264ae99d2b57",
        "ranaze_step3_prd": "780e2f555fad6a59d12f43e7c423b03fe2132c488adc8f9bfed9264ae99d2b57"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next study for uncomplicated suspected statin-associated myalgia without focal neurologic findings or weakness."
            },
            {
              "id": "B",
              "text": "Option B: Erythrocyte sedimentation rate is nonspecific and does not directly evaluate possible statin-associated muscle injury."
            },
            {
              "id": "C",
              "text": "Option C: Quadriceps muscle biopsy is inappropriate because muscle biopsy is too invasive for the initial evaluation of probable medication-related myalgia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next study for uncomplicated suspected statin-associated myalgia without focal neurologic findings or weakness."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Erythrocyte sedimentation rate is nonspecific and does not directly evaluate possible statin-associated muscle injury."
            },
            {
              "id": "B",
              "text": "Option A: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next study for uncomplicated suspected statin-associated myalgia without focal neurologic findings or weakness."
            },
            {
              "id": "C",
              "text": "Option C: Quadriceps muscle biopsy is inappropriate because muscle biopsy is too invasive for the initial evaluation of probable medication-related myalgia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Erythrocyte sedimentation rate is nonspecific and does not directly evaluate possible statin-associated muscle injury."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Quadriceps muscle biopsy is inappropriate because muscle biopsy is too invasive for the initial evaluation of probable medication-related myalgia."
            },
            {
              "id": "B",
              "text": "Option A: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next study for uncomplicated suspected statin-associated myalgia without focal neurologic findings or weakness."
            },
            {
              "id": "C",
              "text": "Option B: Erythrocyte sedimentation rate is nonspecific and does not directly evaluate possible statin-associated muscle injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Quadriceps muscle biopsy is inappropriate because muscle biopsy is too invasive for the initial evaluation of probable medication-related myalgia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urinalysis and urine culture do not address the likely cause of his diffuse muscle soreness and are not the best diagnostic study here."
            },
            {
              "id": "B",
              "text": "Option A: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next study for uncomplicated suspected statin-associated myalgia without focal neurologic findings or weakness."
            },
            {
              "id": "C",
              "text": "Option B: Erythrocyte sedimentation rate is nonspecific and does not directly evaluate possible statin-associated muscle injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urinalysis and urine culture do not address the likely cause of his diffuse muscle soreness and are not the best diagnostic study here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum thyroid-stimulating hormone concentration is inappropriate because thyroid dysfunction can contribute to muscle symptoms, but in this vignette the immediate next study for suspected statin-related myalgia is creatine kinase."
            },
            {
              "id": "B",
              "text": "Option A: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next study for uncomplicated suspected statin-associated myalgia without focal neurologic findings or weakness."
            },
            {
              "id": "C",
              "text": "Option B: Erythrocyte sedimentation rate is nonspecific and does not directly evaluate possible statin-associated muscle injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum thyroid-stimulating hormone concentration is inappropriate because thyroid dysfunction can contribute to muscle symptoms, but in this vignette the immediate next study for suspected statin-related myalgia is creatine kinase."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No study is indicated at this time is inappropriate because a study is indicated because he has persistent myalgias after starting a statin, including pain at rest that is not fully explained by exercise alone."
            },
            {
              "id": "B",
              "text": "Option A: Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is not the best next study for uncomplicated suspected statin-associated myalgia without focal neurologic findings or weakness."
            },
            {
              "id": "C",
              "text": "Option B: Erythrocyte sedimentation rate is nonspecific and does not directly evaluate possible statin-associated muscle injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No study is indicated at this time is inappropriate because a study is indicated because he has persistent myalgias after starting a statin, including pain at rest that is not fully explained by exercise alone."
        }
      }
    },
    {
      "externalId": "nbme6-s4-i049-pertussis-prognosis-infant",
      "expectedHashes": {
        "ranaze_step3_uat": "3211af235f656c1442b1242244e2274301f8eaa133ba68e9e5144fbcd516add4",
        "ranaze_step3_prd": "3211af235f656c1442b1242244e2274301f8eaa133ba68e9e5144fbcd516add4"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She is likely to have permanent lung damage from this infection is inappropriate because permanent structural lung damage is not the usual outcome of pertussis in an otherwise healthy infant who receives appropriate care."
            },
            {
              "id": "B",
              "text": "Option C: This illness usually causes lasting neurologic impairment after apnea is inappropriate because apnea can occur in infants with pertussis, but lasting neurologic impairment is not the expected outcome when recovery is otherwise progressing."
            },
            {
              "id": "C",
              "text": "Option D: She will not need routine pertussis vaccination after she recovers is inappropriate because natural infection does not replace routine immunization; she should still receive age-appropriate pertussis-containing vaccines after recovery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She is likely to have permanent lung damage from this infection is inappropriate because permanent structural lung damage is not the usual outcome of pertussis in an otherwise healthy infant who receives appropriate care."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This illness usually causes lasting neurologic impairment after apnea is inappropriate because apnea can occur in infants with pertussis, but lasting neurologic impairment is not the expected outcome when recovery is otherwise progressing."
            },
            {
              "id": "B",
              "text": "Option A: She is likely to have permanent lung damage from this infection is inappropriate because permanent structural lung damage is not the usual outcome of pertussis in an otherwise healthy infant who receives appropriate care."
            },
            {
              "id": "C",
              "text": "Option D: She will not need routine pertussis vaccination after she recovers is inappropriate because natural infection does not replace routine immunization; she should still receive age-appropriate pertussis-containing vaccines after recovery."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This illness usually causes lasting neurologic impairment after apnea is inappropriate because apnea can occur in infants with pertussis, but lasting neurologic impairment is not the expected outcome when recovery is otherwise progressing."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She will not need routine pertussis vaccination after she recovers is inappropriate because natural infection does not replace routine immunization; she should still receive age-appropriate pertussis-containing vaccines after recovery."
            },
            {
              "id": "B",
              "text": "Option A: She is likely to have permanent lung damage from this infection is inappropriate because permanent structural lung damage is not the usual outcome of pertussis in an otherwise healthy infant who receives appropriate care."
            },
            {
              "id": "C",
              "text": "Option C: This illness usually causes lasting neurologic impairment after apnea is inappropriate because apnea can occur in infants with pertussis, but lasting neurologic impairment is not the expected outcome when recovery is otherwise progressing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She will not need routine pertussis vaccination after she recovers is inappropriate because natural infection does not replace routine immunization; she should still receive age-appropriate pertussis-containing vaccines after recovery."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The coughing illness should resolve on its own within the next 24 hours without further risk is inappropriate because pertussis is not a brief self-limited illness over the next day; infants can have prolonged coughing spells and may require ongoing monitoring."
            },
            {
              "id": "B",
              "text": "Option A: She is likely to have permanent lung damage from this infection is inappropriate because permanent structural lung damage is not the usual outcome of pertussis in an otherwise healthy infant who receives appropriate care."
            },
            {
              "id": "C",
              "text": "Option C: This illness usually causes lasting neurologic impairment after apnea is inappropriate because apnea can occur in infants with pertussis, but lasting neurologic impairment is not the expected outcome when recovery is otherwise progressing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The coughing illness should resolve on its own within the next 24 hours without further risk is inappropriate because pertussis is not a brief self-limited illness over the next day; infants can have prolonged coughing spells and may require ongoing monitoring."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This infection provides complete lifelong protection against future pertussis is inappropriate because pertussis infection does not provide complete lifelong immunity, and future vaccination is still required."
            },
            {
              "id": "B",
              "text": "Option A: She is likely to have permanent lung damage from this infection is inappropriate because permanent structural lung damage is not the usual outcome of pertussis in an otherwise healthy infant who receives appropriate care."
            },
            {
              "id": "C",
              "text": "Option C: This illness usually causes lasting neurologic impairment after apnea is inappropriate because apnea can occur in infants with pertussis, but lasting neurologic impairment is not the expected outcome when recovery is otherwise progressing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This infection provides complete lifelong protection against future pertussis is inappropriate because pertussis infection does not provide complete lifelong immunity, and future vaccination is still required."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She will probably need long-term home oxygen after discharge is inappropriate because long-term oxygen dependence is not the usual prognosis in an infant recovering from pertussis without underlying lung disease."
            },
            {
              "id": "B",
              "text": "Option A: She is likely to have permanent lung damage from this infection is inappropriate because permanent structural lung damage is not the usual outcome of pertussis in an otherwise healthy infant who receives appropriate care."
            },
            {
              "id": "C",
              "text": "Option C: This illness usually causes lasting neurologic impairment after apnea is inappropriate because apnea can occur in infants with pertussis, but lasting neurologic impairment is not the expected outcome when recovery is otherwise progressing."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She will probably need long-term home oxygen after discharge is inappropriate because long-term oxygen dependence is not the usual prognosis in an infant recovering from pertussis without underlying lung disease."
        }
      }
    },
    {
      "externalId": "step3-behavioral-tmj-psychosocial-screening-3214",
      "expectedHashes": {
        "ranaze_step3_uat": "4167cf3922db35e0035d6b334990058632631a7070efac016391c8ca8e99cdb1",
        "ranaze_step3_prd": "4167cf3922db35e0035d6b334990058632631a7070efac016391c8ca8e99cdb1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Prior orthodontic treatment during adolescence is inappropriate because prior orthodontic treatment is not a strong or consistent predictor of temporomandibular disorder severity and does not independently indicate a need for psychosocial screening."
            },
            {
              "id": "B",
              "text": "Option C: Pain beginning after biting hard candy is inappropriate because biting hard candy may have triggered local muscle or joint irritation, but this mechanical event does not by itself indicate a psychosocial contributor."
            },
            {
              "id": "C",
              "text": "Option D: Intermittent clicking with mandibular movement is inappropriate because clicking may reflect disc displacement within the temporomandibular joint but does not independently identify anxiety, depression, or other psychosocial risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Prior orthodontic treatment during adolescence is inappropriate because prior orthodontic treatment is not a strong or consistent predictor of temporomandibular disorder severity and does not independently indicate a need for psychosocial screening."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pain beginning after biting hard candy is inappropriate because biting hard candy may have triggered local muscle or joint irritation, but this mechanical event does not by itself indicate a psychosocial contributor."
            },
            {
              "id": "B",
              "text": "Option B: Prior orthodontic treatment during adolescence is inappropriate because prior orthodontic treatment is not a strong or consistent predictor of temporomandibular disorder severity and does not independently indicate a need for psychosocial screening."
            },
            {
              "id": "C",
              "text": "Option D: Intermittent clicking with mandibular movement is inappropriate because clicking may reflect disc displacement within the temporomandibular joint but does not independently identify anxiety, depression, or other psychosocial risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pain beginning after biting hard candy is inappropriate because biting hard candy may have triggered local muscle or joint irritation, but this mechanical event does not by itself indicate a psychosocial contributor."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intermittent clicking with mandibular movement is inappropriate because clicking may reflect disc displacement within the temporomandibular joint but does not independently identify anxiety, depression, or other psychosocial risk factors."
            },
            {
              "id": "B",
              "text": "Option B: Prior orthodontic treatment during adolescence is inappropriate because prior orthodontic treatment is not a strong or consistent predictor of temporomandibular disorder severity and does not independently indicate a need for psychosocial screening."
            },
            {
              "id": "C",
              "text": "Option C: Pain beginning after biting hard candy is inappropriate because biting hard candy may have triggered local muscle or joint irritation, but this mechanical event does not by itself indicate a psychosocial contributor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intermittent clicking with mandibular movement is inappropriate because clicking may reflect disc displacement within the temporomandibular joint but does not independently identify anxiety, depression, or other psychosocial risk factors."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Age of 29 years is inappropriate because temporomandibular disorders are common in young and middle-aged adults, but age alone does not indicate the need for psychosocial screening."
            },
            {
              "id": "B",
              "text": "Option B: Prior orthodontic treatment during adolescence is inappropriate because prior orthodontic treatment is not a strong or consistent predictor of temporomandibular disorder severity and does not independently indicate a need for psychosocial screening."
            },
            {
              "id": "C",
              "text": "Option C: Pain beginning after biting hard candy is inappropriate because biting hard candy may have triggered local muscle or joint irritation, but this mechanical event does not by itself indicate a psychosocial contributor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Age of 29 years is inappropriate because temporomandibular disorders are common in young and middle-aged adults, but age alone does not indicate the need for psychosocial screening."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tenderness of the masseter and temporalis muscles is inappropriate because masseter and temporalis tenderness supports a muscular temporomandibular disorder. It is a physical finding and does not independently identify psychological distress, pain catastrophizing, sleep disturbance, or another psychosocial contributor."
            },
            {
              "id": "B",
              "text": "Option B: Prior orthodontic treatment during adolescence is inappropriate because prior orthodontic treatment is not a strong or consistent predictor of temporomandibular disorder severity and does not independently indicate a need for psychosocial screening."
            },
            {
              "id": "C",
              "text": "Option C: Pain beginning after biting hard candy is inappropriate because biting hard candy may have triggered local muscle or joint irritation, but this mechanical event does not by itself indicate a psychosocial contributor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tenderness of the masseter and temporalis muscles is inappropriate because masseter and temporalis tenderness supports a muscular temporomandibular disorder. It is a physical finding and does not independently identify psychological distress, pain catastrophizing, sleep disturbance, or another psychosocial contributor."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-absolute-risk-reduction-642",
      "expectedHashes": {
        "ranaze_step3_uat": "97ef8c977ac9288a0f948a232ace5c5686270516de9bd04ced98d99fe0106330",
        "ranaze_step3_prd": "97ef8c977ac9288a0f948a232ace5c5686270516de9bd04ced98d99fe0106330"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "B",
              "text": "Option C: 0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            },
            {
              "id": "C",
              "text": "Option D: 0.20 is inappropriate because this is the surgery event rate before pathway implementation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "0.05 is inappropriate because this underestimates the difference between the two surgery rates."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            },
            {
              "id": "B",
              "text": "Option A: 0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "C",
              "text": "Option D: 0.20 is inappropriate because this is the surgery event rate before pathway implementation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "0.20 is inappropriate because this is the surgery event rate before pathway implementation."
            },
            {
              "id": "B",
              "text": "Option A: 0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "C",
              "text": "Option C: 0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "0.20 is inappropriate because this is the surgery event rate before pathway implementation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "0.30 is inappropriate because this does not correspond to the absolute difference between the reported surgery rates."
            },
            {
              "id": "B",
              "text": "Option A: 0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "C",
              "text": "Option C: 0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "0.30 is inappropriate because this does not correspond to the absolute difference between the reported surgery rates."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "0.004 is inappropriate because this is the P value for the comparison of surgery rates. A P value addresses compatibility with a null hypothesis; it is not the magnitude of the absolute risk reduction."
            },
            {
              "id": "B",
              "text": "Option A: 0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "C",
              "text": "Option C: 0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "0.004 is inappropriate because this is the P value for the comparison of surgery rates. A P value addresses compatibility with a null hypothesis; it is not the magnitude of the absolute risk reduction."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This is the post-pathway-to-pre-pathway risk ratio: 0.14/0.20 = 0.70. A risk ratio is a quotient, whereas ARR is the difference 0.20 \u00E2\u02C6\u2019 0.14."
            },
            {
              "id": "B",
              "text": "Option A: 0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "C",
              "text": "Option C: 0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This is the post-pathway-to-pre-pathway risk ratio: 0.14/0.20 = 0.70. A risk ratio is a quotient, whereas ARR is the difference 0.20 \u00E2\u02C6\u2019 0.14."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "-0.06 is inappropriate because this results from reversing the subtraction: 0.14 \u00E2\u02C6\u2019 0.20 = \u00E2\u02C6\u20190.06. ARR for an adverse event is conventionally stated as baseline risk minus intervention risk, yielding positive 0.06."
            },
            {
              "id": "B",
              "text": "Option A: 0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "C",
              "text": "Option C: 0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "-0.06 is inappropriate because this results from reversing the subtraction: 0.14 \u00E2\u02C6\u2019 0.20 = \u00E2\u02C6\u20190.06. ARR for an adverse event is conventionally stated as baseline risk minus intervention risk, yielding positive 0.06."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This can result from subtracting the raw surgery counts and dividing by the pre-pathway total: (540 \u00E2\u02C6\u2019 350)/2700 \u00E2\u2030\u02C6 0.07. The groups have different denominators, so their risks must be calculated separately before subtraction."
            },
            {
              "id": "B",
              "text": "Option A: 0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "C",
              "text": "Option C: 0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This can result from subtracting the raw surgery counts and dividing by the pre-pathway total: (540 \u00E2\u02C6\u2019 350)/2700 \u00E2\u2030\u02C6 0.07. The groups have different denominators, so their risks must be calculated separately before subtraction."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This is approximately the odds ratio for lumbar surgery after versus before pathway implementation: (0.14/0.86)/(0.20/0.80) \u00E2\u2030\u02C6 0.65. The requested absolute risk reduction is a difference in risks, 0.20 \u00E2\u02C6\u2019 0.14 = 0.06, rather than a ratio of odds."
            },
            {
              "id": "B",
              "text": "Option A: 0.05 is inappropriate because this underestimates the difference between the two surgery rates."
            },
            {
              "id": "C",
              "text": "Option C: 0.14 is inappropriate because this is the post-pathway surgery event rate, not the absolute risk reduction."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This is approximately the odds ratio for lumbar surgery after versus before pathway implementation: (0.14/0.86)/(0.20/0.80) \u00E2\u2030\u02C6 0.65. The requested absolute risk reduction is a difference in risks, 0.20 \u00E2\u02C6\u2019 0.14 = 0.06, rather than a ratio of odds."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-clinical-vs-statistical-significance-2428",
      "expectedHashes": {
        "ranaze_step3_uat": "0bbfb34fedf9c30a7eba7ea44f7bb3eaabd0995291c88081a9b8c37d4be1afc9",
        "ranaze_step3_prd": "0bbfb34fedf9c30a7eba7ea44f7bb3eaabd0995291c88081a9b8c37d4be1afc9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Clinically significant but statistically insignificant is inappropriate because a P value below 0.05 indicates statistical significance, whereas the small between-group difference is unlikely to be clinically meaningful."
            },
            {
              "id": "B",
              "text": "Option C: Both clinically and statistically significant is inappropriate because although the result is statistically significant, an incremental reduction of only 1.7 mm Hg is not a substantial therapeutic effect."
            },
            {
              "id": "C",
              "text": "Option D: Neither clinically nor statistically significant is inappropriate because the effect is statistically significant because the P value is 0.01."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Clinically significant but statistically insignificant is inappropriate because a P value below 0.05 indicates statistical significance, whereas the small between-group difference is unlikely to be clinically meaningful."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Both clinically and statistically significant is inappropriate because although the result is statistically significant, an incremental reduction of only 1.7 mm Hg is not a substantial therapeutic effect."
            },
            {
              "id": "B",
              "text": "Option B: Clinically significant but statistically insignificant is inappropriate because a P value below 0.05 indicates statistical significance, whereas the small between-group difference is unlikely to be clinically meaningful."
            },
            {
              "id": "C",
              "text": "Option D: Neither clinically nor statistically significant is inappropriate because the effect is statistically significant because the P value is 0.01."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Both clinically and statistically significant is inappropriate because although the result is statistically significant, an incremental reduction of only 1.7 mm Hg is not a substantial therapeutic effect."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neither clinically nor statistically significant is inappropriate because the effect is statistically significant because the P value is 0.01."
            },
            {
              "id": "B",
              "text": "Option B: Clinically significant but statistically insignificant is inappropriate because a P value below 0.05 indicates statistical significance, whereas the small between-group difference is unlikely to be clinically meaningful."
            },
            {
              "id": "C",
              "text": "Option C: Both clinically and statistically significant is inappropriate because although the result is statistically significant, an incremental reduction of only 1.7 mm Hg is not a substantial therapeutic effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neither clinically nor statistically significant is inappropriate because the effect is statistically significant because the P value is 0.01."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The clinical significance cannot be assessed because the P value is less than 0.05 is inappropriate because clinical significance is assessed from the magnitude and practical importance of the effect, not from the P value alone."
            },
            {
              "id": "B",
              "text": "Option B: Clinically significant but statistically insignificant is inappropriate because a P value below 0.05 indicates statistical significance, whereas the small between-group difference is unlikely to be clinically meaningful."
            },
            {
              "id": "C",
              "text": "Option C: Both clinically and statistically significant is inappropriate because although the result is statistically significant, an incremental reduction of only 1.7 mm Hg is not a substantial therapeutic effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The clinical significance cannot be assessed because the P value is less than 0.05 is inappropriate because clinical significance is assessed from the magnitude and practical importance of the effect, not from the P value alone."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The new medication is noninferior but not superior to standard therapy is inappropriate because noninferiority requires a prespecified noninferiority margin and corresponding analysis. The reported superiority comparison is statistically significant because the new medication produced a greater reduction with P=0.01."
            },
            {
              "id": "B",
              "text": "Option B: Clinically significant but statistically insignificant is inappropriate because a P value below 0.05 indicates statistical significance, whereas the small between-group difference is unlikely to be clinically meaningful."
            },
            {
              "id": "C",
              "text": "Option C: Both clinically and statistically significant is inappropriate because although the result is statistically significant, an incremental reduction of only 1.7 mm Hg is not a substantial therapeutic effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The new medication is noninferior but not superior to standard therapy is inappropriate because noninferiority requires a prespecified noninferiority margin and corresponding analysis. The reported superiority comparison is statistically significant because the new medication produced a greater reduction with P=0.01."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The incremental effect cannot be interpreted without each group\u2019s baseline blood pressure is inappropriate because baseline values can aid interpretation, but the adjusted between-group difference directly estimates the incremental treatment effect. Its small magnitude and reported P value allow assessment of clinical and statistical significance."
            },
            {
              "id": "B",
              "text": "Option B: Clinically significant but statistically insignificant is inappropriate because a P value below 0.05 indicates statistical significance, whereas the small between-group difference is unlikely to be clinically meaningful."
            },
            {
              "id": "C",
              "text": "Option C: Both clinically and statistically significant is inappropriate because although the result is statistically significant, an incremental reduction of only 1.7 mm Hg is not a substantial therapeutic effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The incremental effect cannot be interpreted without each group\u2019s baseline blood pressure is inappropriate because baseline values can aid interpretation, but the adjusted between-group difference directly estimates the incremental treatment effect. Its small magnitude and reported P value allow assessment of clinical and statistical significance."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Statistical significance cannot be determined without a confidence interval is inappropriate because a confidence interval would show the estimate\u2019s precision, but P=0.01 is sufficient to identify statistical significance at the conventional 0.05 level."
            },
            {
              "id": "B",
              "text": "Option B: Clinically significant but statistically insignificant is inappropriate because a P value below 0.05 indicates statistical significance, whereas the small between-group difference is unlikely to be clinically meaningful."
            },
            {
              "id": "C",
              "text": "Option C: Both clinically and statistically significant is inappropriate because although the result is statistically significant, an incremental reduction of only 1.7 mm Hg is not a substantial therapeutic effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Statistical significance cannot be determined without a confidence interval is inappropriate because a confidence interval would show the estimate\u2019s precision, but P=0.01 is sufficient to identify statistical significance at the conventional 0.05 level."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-diagnostic-test-positive-predictive-value-1107",
      "expectedHashes": {
        "ranaze_step3_uat": "e9e86c495a4a798cfc6de6ecb4629c1643a6dc5fc0a0ed6e0eb05b13e2e8d2ce",
        "ranaze_step3_prd": "e9e86c495a4a798cfc6de6ecb4629c1643a6dc5fc0a0ed6e0eb05b13e2e8d2ce"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "B",
              "text": "Option C: Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            },
            {
              "id": "C",
              "text": "Option D: Tachypnea has a higher positive predictive value than subcostal retractions. is inappropriate because the PPV of tachypnea is 144/(144\u002B64), approximately 69%, whereas the PPV of subcostal retractions is 48/(48\u002B8), approximately 86%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            },
            {
              "id": "B",
              "text": "Option B: The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "C",
              "text": "Option D: Tachypnea has a higher positive predictive value than subcostal retractions. is inappropriate because the PPV of tachypnea is 144/(144\u002B64), approximately 69%, whereas the PPV of subcostal retractions is 48/(48\u002B8), approximately 86%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tachypnea has a higher positive predictive value than subcostal retractions. is inappropriate because the PPV of tachypnea is 144/(144\u002B64), approximately 69%, whereas the PPV of subcostal retractions is 48/(48\u002B8), approximately 86%."
            },
            {
              "id": "B",
              "text": "Option B: The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "C",
              "text": "Option C: Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tachypnea has a higher positive predictive value than subcostal retractions. is inappropriate because the PPV of tachypnea is 144/(144\u002B64), approximately 69%, whereas the PPV of subcostal retractions is 48/(48\u002B8), approximately 86%."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcostal retractions should be used as the sole screening criterion for pneumonia. is inappropriate because subcostal retractions have only 20% sensitivity and would miss most children with pneumonia if used as the sole screening criterion."
            },
            {
              "id": "B",
              "text": "Option B: The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "C",
              "text": "Option C: Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcostal retractions should be used as the sole screening criterion for pneumonia. is inappropriate because subcostal retractions have only 20% sensitivity and would miss most children with pneumonia if used as the sole screening criterion."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Crackles have the highest positive predictive value for pneumonia because they occur in the greatest number of children with pneumonia. is inappropriate because pPV depends on all patients with the finding, not the true-positive count alone. Crackles have a PPV of 168/(168\u002B80)=67.7%, compared with 92.3% for central cyanosis."
            },
            {
              "id": "B",
              "text": "Option B: The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "C",
              "text": "Option C: Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Crackles have the highest positive predictive value for pneumonia because they occur in the greatest number of children with pneumonia. is inappropriate because pPV depends on all patients with the finding, not the true-positive count alone. Crackles have a PPV of 168/(168\u002B80)=67.7%, compared with 92.3% for central cyanosis."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Central cyanosis has 98.8% sensitivity for pneumonia. is inappropriate because the table reports 98.8% specificity but only 10% sensitivity for central cyanosis."
            },
            {
              "id": "B",
              "text": "Option B: The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "C",
              "text": "Option C: Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Central cyanosis has 98.8% sensitivity for pneumonia. is inappropriate because the table reports 98.8% specificity but only 10% sensitivity for central cyanosis."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The 98.8% specificity of central cyanosis means that 98.8% of children with central cyanosis have pneumonia. is inappropriate because this substitutes the definition of PPV for specificity. The proportion of children with cyanosis who have pneumonia is 24/(24\u002B2)=92.3%, not 98.8%."
            },
            {
              "id": "B",
              "text": "Option B: The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "C",
              "text": "Option C: Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The 98.8% specificity of central cyanosis means that 98.8% of children with central cyanosis have pneumonia. is inappropriate because this substitutes the definition of PPV for specificity. The proportion of children with cyanosis who have pneumonia is 24/(24\u002B2)=92.3%, not 98.8%."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Central cyanosis has the lowest false-negative rate among the listed findings. is inappropriate because central cyanosis detects only 24 of 240 pneumonia cases, giving it a 90% false-negative rate\u00E2\u20AC\u201Dthe highest, not the lowest, among the listed findings."
            },
            {
              "id": "B",
              "text": "Option B: The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "C",
              "text": "Option C: Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Central cyanosis has the lowest false-negative rate among the listed findings. is inappropriate because central cyanosis detects only 24 of 240 pneumonia cases, giving it a 90% false-negative rate\u00E2\u20AC\u201Dthe highest, not the lowest, among the listed findings."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Central cyanosis occurs in 98.8% of children without pneumonia. is inappropriate because specificity of 98.8% means 98.8% of children without pneumonia lack central cyanosis. Only 2 of 160 children without pneumonia have it."
            },
            {
              "id": "B",
              "text": "Option B: The absence of central cyanosis reliably excludes pneumonia. is inappropriate because central cyanosis has only 10% sensitivity, so most children with pneumonia do not have this finding; its absence cannot reliably exclude disease."
            },
            {
              "id": "C",
              "text": "Option C: Crackles are necessary for the diagnosis of pneumonia. is inappropriate because crackles have 70% sensitivity, meaning they are absent in 30% of children with pneumonia and are therefore not necessary for diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Central cyanosis occurs in 98.8% of children without pneumonia. is inappropriate because specificity of 98.8% means 98.8% of children without pneumonia lack central cyanosis. Only 2 of 160 children without pneumonia have it."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-diagnostic-threshold-sensitivity-specificity-3976",
      "expectedHashes": {
        "ranaze_step3_uat": "6f85ac3ee20cd8b4efb4c8ffc4c23029aa5427b33dbc3266b2fc33d80df872a3",
        "ranaze_step3_prd": "6f85ac3ee20cd8b4efb4c8ffc4c23029aa5427b33dbc3266b2fc33d80df872a3"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sensitivity will increase, and specificity will decrease is inappropriate because this describes the effect of lowering, rather than raising, the cutoff. A lower threshold captures more true positives but also produces more false positives."
            },
            {
              "id": "B",
              "text": "Option C: Sensitivity and specificity will both increase is inappropriate because sensitivity and specificity generally trade off when only the cutoff of a continuous diagnostic test is changed."
            },
            {
              "id": "C",
              "text": "Option D: Sensitivity and specificity will both decrease is inappropriate because raising the threshold improves rather than decreases specificity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sensitivity will increase, and specificity will decrease is inappropriate because this describes the effect of lowering, rather than raising, the cutoff. A lower threshold captures more true positives but also produces more false positives."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sensitivity and specificity will both increase is inappropriate because sensitivity and specificity generally trade off when only the cutoff of a continuous diagnostic test is changed."
            },
            {
              "id": "B",
              "text": "Option A: Sensitivity will increase, and specificity will decrease is inappropriate because this describes the effect of lowering, rather than raising, the cutoff. A lower threshold captures more true positives but also produces more false positives."
            },
            {
              "id": "C",
              "text": "Option D: Sensitivity and specificity will both decrease is inappropriate because raising the threshold improves rather than decreases specificity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sensitivity and specificity will both increase is inappropriate because sensitivity and specificity generally trade off when only the cutoff of a continuous diagnostic test is changed."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sensitivity and specificity will both decrease is inappropriate because raising the threshold improves rather than decreases specificity."
            },
            {
              "id": "B",
              "text": "Option A: Sensitivity will increase, and specificity will decrease is inappropriate because this describes the effect of lowering, rather than raising, the cutoff. A lower threshold captures more true positives but also produces more false positives."
            },
            {
              "id": "C",
              "text": "Option C: Sensitivity and specificity will both increase is inappropriate because sensitivity and specificity generally trade off when only the cutoff of a continuous diagnostic test is changed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sensitivity and specificity will both decrease is inappropriate because raising the threshold improves rather than decreases specificity."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sensitivity will remain unchanged, and specificity will increase is inappropriate because sensitivity decreases because patients with cancer whose values are between 35 and 50 U/mL are reclassified as having negative results."
            },
            {
              "id": "B",
              "text": "Option A: Sensitivity will increase, and specificity will decrease is inappropriate because this describes the effect of lowering, rather than raising, the cutoff. A lower threshold captures more true positives but also produces more false positives."
            },
            {
              "id": "C",
              "text": "Option C: Sensitivity and specificity will both increase is inappropriate because sensitivity and specificity generally trade off when only the cutoff of a continuous diagnostic test is changed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sensitivity will remain unchanged, and specificity will increase is inappropriate because sensitivity decreases because patients with cancer whose values are between 35 and 50 U/mL are reclassified as having negative results."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The area under the receiver operating characteristic curve will increase is inappropriate because changing the cutoff selects a different operating point on the same receiver operating characteristic curve. Because the assay, reference standard, and population are unchanged, the ROC curve and its area do not improve merely by selecting a higher threshold."
            },
            {
              "id": "B",
              "text": "Option A: Sensitivity will increase, and specificity will decrease is inappropriate because this describes the effect of lowering, rather than raising, the cutoff. A lower threshold captures more true positives but also produces more false positives."
            },
            {
              "id": "C",
              "text": "Option C: Sensitivity and specificity will both increase is inappropriate because sensitivity and specificity generally trade off when only the cutoff of a continuous diagnostic test is changed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The area under the receiver operating characteristic curve will increase is inappropriate because changing the cutoff selects a different operating point on the same receiver operating characteristic curve. Because the assay, reference standard, and population are unchanged, the ROC curve and its area do not improve merely by selecting a higher threshold."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-intention-to-treat-412",
      "expectedHashes": {
        "ranaze_step3_uat": "26ac281fe4d8a2b6f27507784c435e5242eec041bda088119fc6f50a8e616934",
        "ranaze_step3_prd": "26ac281fe4d8a2b6f27507784c435e5242eec041bda088119fc6f50a8e616934"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Per-protocol analysis includes only participants who sufficiently adhered to the assigned intervention and would exclude or reclassify many participants in this study."
            },
            {
              "id": "B",
              "text": "Option C: Subgroup analysis examines outcomes within predefined subsets (eg, age or sex) and is unrelated to maintaining randomized assignment."
            },
            {
              "id": "C",
              "text": "Option D: Logistic regression is a statistical modeling technique for binary outcomes and does not describe how participants are assigned for analysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Per-protocol analysis includes only participants who sufficiently adhered to the assigned intervention and would exclude or reclassify many participants in this study."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subgroup analysis examines outcomes within predefined subsets (eg, age or sex) and is unrelated to maintaining randomized assignment."
            },
            {
              "id": "B",
              "text": "Option B: Per-protocol analysis includes only participants who sufficiently adhered to the assigned intervention and would exclude or reclassify many participants in this study."
            },
            {
              "id": "C",
              "text": "Option D: Logistic regression is a statistical modeling technique for binary outcomes and does not describe how participants are assigned for analysis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subgroup analysis examines outcomes within predefined subsets (eg, age or sex) and is unrelated to maintaining randomized assignment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Logistic regression is a statistical modeling technique for binary outcomes and does not describe how participants are assigned for analysis."
            },
            {
              "id": "B",
              "text": "Option B: Per-protocol analysis includes only participants who sufficiently adhered to the assigned intervention and would exclude or reclassify many participants in this study."
            },
            {
              "id": "C",
              "text": "Option C: Subgroup analysis examines outcomes within predefined subsets (eg, age or sex) and is unrelated to maintaining randomized assignment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Logistic regression is a statistical modeling technique for binary outcomes and does not describe how participants are assigned for analysis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "As-treated analysis classifies participants according to the treatment they actually received rather than their randomized assignment."
            },
            {
              "id": "B",
              "text": "Option B: Per-protocol analysis includes only participants who sufficiently adhered to the assigned intervention and would exclude or reclassify many participants in this study."
            },
            {
              "id": "C",
              "text": "Option C: Subgroup analysis examines outcomes within predefined subsets (eg, age or sex) and is unrelated to maintaining randomized assignment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "As-treated analysis classifies participants according to the treatment they actually received rather than their randomized assignment."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Modified intention-to-treat analysis excluding participants who never initiated their assigned inhaler is inappropriate because this explicitly restricted modified-ITT approach would exclude a subset of randomized participants. The investigators instead retained participants in their original groups regardless of adherence or treatment received, which is the defining ITT principle."
            },
            {
              "id": "B",
              "text": "Option B: Per-protocol analysis includes only participants who sufficiently adhered to the assigned intervention and would exclude or reclassify many participants in this study."
            },
            {
              "id": "C",
              "text": "Option C: Subgroup analysis examines outcomes within predefined subsets (eg, age or sex) and is unrelated to maintaining randomized assignment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Modified intention-to-treat analysis excluding participants who never initiated their assigned inhaler is inappropriate because this explicitly restricted modified-ITT approach would exclude a subset of randomized participants. The investigators instead retained participants in their original groups regardless of adherence or treatment received, which is the defining ITT principle."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-number-needed-to-harm-303",
      "expectedHashes": {
        "ranaze_step3_uat": "e3c6e84efcc6ae33190541052be4191c4330afd144b0d293cee050197c29cf36",
        "ranaze_step3_prd": "e3c6e84efcc6ae33190541052be4191c4330afd144b0d293cee050197c29cf36"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
            },
            {
              "id": "B",
              "text": "Option B: 25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
            },
            {
              "id": "C",
              "text": "Option C: 40 is inappropriate because this would correspond to an absolute risk increase of 2.5%, not the observed 2%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
            },
            {
              "id": "B",
              "text": "Option A: 20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
            },
            {
              "id": "C",
              "text": "Option C: 40 is inappropriate because this would correspond to an absolute risk increase of 2.5%, not the observed 2%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "40 is inappropriate because this would correspond to an absolute risk increase of 2.5%, not the observed 2%."
            },
            {
              "id": "B",
              "text": "Option A: 20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
            },
            {
              "id": "C",
              "text": "Option B: 25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "40 is inappropriate because this would correspond to an absolute risk increase of 2.5%, not the observed 2%."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "100 is inappropriate because this would correspond to an absolute risk increase of 1%, which is smaller than the observed 2% increase."
            },
            {
              "id": "B",
              "text": "Option A: 20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
            },
            {
              "id": "C",
              "text": "Option B: 25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "100 is inappropriate because this would correspond to an absolute risk increase of 1%, which is smaller than the observed 2% increase."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This is the number needed to treat to prevent one symptomatic venous thromboembolism: 1/(0.041\u22120.025)=62.5, conventionally rounded up to 63. The question asks about additional major bleeding, whose absolute risk increase is 0.020 and whose reciprocal is 50."
            },
            {
              "id": "B",
              "text": "Option A: 20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
            },
            {
              "id": "C",
              "text": "Option B: 25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This is the number needed to treat to prevent one symptomatic venous thromboembolism: 1/(0.041\u22120.025)=62.5, conventionally rounded up to 63. The question asks about additional major bleeding, whose absolute risk increase is 0.020 and whose reciprocal is 50."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This is obtained from the reciprocal of the standard-prophylaxis group\u0027s 2.8% bleeding risk: 1/0.028=35.7, rounded up to 36. The comparator event rate alone is not the absolute risk increase attributable to the new drug."
            },
            {
              "id": "B",
              "text": "Option A: 20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
            },
            {
              "id": "C",
              "text": "Option B: 25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This is obtained from the reciprocal of the standard-prophylaxis group\u0027s 2.8% bleeding risk: 1/0.028=35.7, rounded up to 36. The comparator event rate alone is not the absolute risk increase attributable to the new drug."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Major bleeding increased by approximately 71% relative to the comparator: (4.8\u22122.8)/2.8=0.714. Treating that relative percentage as a patient count confuses relative risk increase with number needed to harm."
            },
            {
              "id": "B",
              "text": "Option A: 20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
            },
            {
              "id": "C",
              "text": "Option B: 25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Major bleeding increased by approximately 71% relative to the comparator: (4.8\u22122.8)/2.8=0.714. Treating that relative percentage as a patient count confuses relative risk increase with number needed to harm."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Multiplying the 2% absolute risk increase by 2400 gives 48 excess events per 2400 comparably treated patients. That is an excess-event count for a specified population, not the number of patients required to produce one additional event; the latter is 1/0.02=50."
            },
            {
              "id": "B",
              "text": "Option A: 20 is inappropriate because this would correspond to an absolute risk increase of 5%, which is larger than the 2% increase reported."
            },
            {
              "id": "C",
              "text": "Option B: 25 is inappropriate because this would correspond to an absolute risk increase of 4%, not the observed 2%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Multiplying the 2% absolute risk increase by 2400 gives 48 excess events per 2400 comparably treated patients. That is an excess-event count for a specified population, not the number of patients required to produce one additional event; the latter is 1/0.02=50."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-odds-ratio-confidence-interval-417",
      "expectedHashes": {
        "ranaze_step3_uat": "818c8797345a437aad5ebc4365dcb761da60ea1767d42188feef5768735c8626",
        "ranaze_step3_prd": "818c8797345a437aad5ebc4365dcb761da60ea1767d42188feef5768735c8626"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
            },
            {
              "id": "B",
              "text": "Option C: The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
            },
            {
              "id": "C",
              "text": "Option D: The conclusion is not supported because odds ratios cannot be used in case-control studies is inappropriate because odds ratios are the standard measure of association in case-control studies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
            },
            {
              "id": "B",
              "text": "Option B: The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
            },
            {
              "id": "C",
              "text": "Option D: The conclusion is not supported because odds ratios cannot be used in case-control studies is inappropriate because odds ratios are the standard measure of association in case-control studies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The conclusion is not supported because odds ratios cannot be used in case-control studies is inappropriate because odds ratios are the standard measure of association in case-control studies."
            },
            {
              "id": "B",
              "text": "Option B: The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
            },
            {
              "id": "C",
              "text": "Option C: The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The conclusion is not supported because odds ratios cannot be used in case-control studies is inappropriate because odds ratios are the standard measure of association in case-control studies."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The conclusion is supported because the study included more controls than cases is inappropriate because using more controls can improve precision, but it does not establish significance when the confidence interval includes 1.0."
            },
            {
              "id": "B",
              "text": "Option B: The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
            },
            {
              "id": "C",
              "text": "Option C: The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The conclusion is supported because the study included more controls than cases is inappropriate because using more controls can improve precision, but it does not establish significance when the confidence interval includes 1.0."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The conclusion is supported because the 95% confidence interval excludes 0 is inappropriate because zero is the null value for differences, not ratios. The null value for an odds ratio is 1.0, which lies within 0.88-3.32; therefore the result is not statistically significant."
            },
            {
              "id": "B",
              "text": "Option B: The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
            },
            {
              "id": "C",
              "text": "Option C: The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The conclusion is supported because the 95% confidence interval excludes 0 is inappropriate because zero is the null value for differences, not ratios. The null value for an odds ratio is 1.0, which lies within 0.88-3.32; therefore the result is not statistically significant."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The conclusion is supported because age matching eliminates confounding is inappropriate because matching controls to cases by age addresses potential confounding by age but does not eliminate other confounding and cannot override a confidence interval that includes the null value."
            },
            {
              "id": "B",
              "text": "Option B: The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
            },
            {
              "id": "C",
              "text": "Option C: The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The conclusion is supported because age matching eliminates confounding is inappropriate because matching controls to cases by age addresses potential confounding by age but does not eliminate other confounding and cannot override a confidence interval that includes the null value."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The conclusion is supported because enrolling newly diagnosed cases eliminates recall bias is inappropriate because selecting newly diagnosed cases can reduce some temporal complications but does not eliminate differential recall of diet over the preceding 5 years. More importantly, it does not make the reported association statistically significant."
            },
            {
              "id": "B",
              "text": "Option B: The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
            },
            {
              "id": "C",
              "text": "Option C: The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The conclusion is supported because enrolling newly diagnosed cases eliminates recall bias is inappropriate because selecting newly diagnosed cases can reduce some temporal complications but does not eliminate differential recall of diet over the preceding 5 years. More importantly, it does not make the reported association statistically significant."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The study proves that processed-meat consumption has no association with pancreatic cancer is inappropriate because failure to reject the null hypothesis does not prove that no association exists. The wide interval includes both no association and potentially important increased odds, so the appropriate interpretation is inconclusive."
            },
            {
              "id": "B",
              "text": "Option B: The conclusion is supported because the odds ratio is greater than 1 is inappropriate because an odds ratio greater than 1 suggests a positive association, but statistical significance depends on whether the confidence interval excludes 1.0."
            },
            {
              "id": "C",
              "text": "Option C: The conclusion is supported because a case-control study can calculate disease incidence is inappropriate because case-control studies begin with disease status and generally cannot directly calculate incidence or relative risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The study proves that processed-meat consumption has no association with pancreatic cancer is inappropriate because failure to reject the null hypothesis does not prove that no association exists. The wide interval includes both no association and potentially important increased odds, so the appropriate interpretation is inconclusive."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-prevalence-negative-predictive-value-2516",
      "expectedHashes": {
        "ranaze_step3_uat": "433ef82df39df8b223db2851720e2f9d9d3e3184c6593c1045db4ed3f59c8618",
        "ranaze_step3_prd": "433ef82df39df8b223db2851720e2f9d9d3e3184c6593c1045db4ed3f59c8618"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "B",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option D: Higher positive predictive value is inappropriate because positive predictive value decreases, rather than increases, when disease prevalence is lower."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option D: Higher positive predictive value is inappropriate because positive predictive value decreases, rather than increases, when disease prevalence is lower."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Higher positive predictive value is inappropriate because positive predictive value decreases, rather than increases, when disease prevalence is lower."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Higher positive predictive value is inappropriate because positive predictive value decreases, rather than increases, when disease prevalence is lower."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Higher false-negative rate is inappropriate because the false-negative rate equals 1 minus sensitivity and remains unchanged because sensitivity is held constant."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Higher false-negative rate is inappropriate because the false-negative rate equals 1 minus sensitivity and remains unchanged because sensitivity is held constant."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower negative predictive value is inappropriate because lower prevalence increases, rather than decreases, negative predictive value because negative results contain a greater proportion of true negatives."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower negative predictive value is inappropriate because lower prevalence increases, rather than decreases, negative predictive value because negative results contain a greater proportion of true negatives."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unchanged negative predictive value is inappropriate because negative predictive value is prevalence-dependent and therefore increases when prevalence falls while sensitivity and specificity remain fixed."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unchanged negative predictive value is inappropriate because negative predictive value is prevalence-dependent and therefore increases when prevalence falls while sensitivity and specificity remain fixed."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower positive likelihood ratio is inappropriate because the positive likelihood ratio remains fixed because sensitivity and specificity are unchanged."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower positive likelihood ratio is inappropriate because the positive likelihood ratio remains fixed because sensitivity and specificity are unchanged."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower negative likelihood ratio is inappropriate because the negative likelihood ratio remains fixed when sensitivity and specificity remain unchanged."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower negative likelihood ratio is inappropriate because the negative likelihood ratio remains fixed when sensitivity and specificity remain unchanged."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unchanged positive predictive value is inappropriate because positive predictive value decreases as prevalence falls; it does not remain at 84%."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unchanged positive predictive value is inappropriate because positive predictive value decreases as prevalence falls; it does not remain at 84%."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower overall diagnostic accuracy is inappropriate because overall accuracy equals sensitivity times prevalence plus specificity times 1 minus prevalence. Here specificity is higher than sensitivity, so lowering prevalence increases\u2014not decreases\u2014the proportion correctly classified."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower overall diagnostic accuracy is inappropriate because overall accuracy equals sensitivity times prevalence plus specificity times 1 minus prevalence. Here specificity is higher than sensitivity, so lowering prevalence increases\u2014not decreases\u2014the proportion correctly classified."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unchanged overall diagnostic accuracy is inappropriate because with sensitivity 58% and specificity 90%, accuracy equals 0.90 minus 0.32 times prevalence. It therefore increases as prevalence decreases rather than remaining unchanged."
            },
            {
              "id": "B",
              "text": "Option B: Higher sensitivity is inappropriate because sensitivity is held constant and therefore does not increase as prevalence decreases."
            },
            {
              "id": "C",
              "text": "Option C: Higher specificity is inappropriate because specificity is held constant and therefore does not change as prevalence decreases."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unchanged overall diagnostic accuracy is inappropriate because with sensitivity 58% and specificity 90%, accuracy equals 0.90 minus 0.32 times prevalence. It therefore increases as prevalence decreases rather than remaining unchanged."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-prevalence-positive-predictive-value-341",
      "expectedHashes": {
        "ranaze_step3_uat": "04eebe5834950bcae4e0d10cf187cf9d1b4fc484a1e48d4bb1afb839c45a7d41",
        "ranaze_step3_prd": "04eebe5834950bcae4e0d10cf187cf9d1b4fc484a1e48d4bb1afb839c45a7d41"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
            },
            {
              "id": "B",
              "text": "Option C: Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
            },
            {
              "id": "C",
              "text": "Option D: Lower specificity is inappropriate because specificity is the probability of a negative result among patients who do not have the disease and is not changed by population prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
            },
            {
              "id": "B",
              "text": "Option B: Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
            },
            {
              "id": "C",
              "text": "Option D: Lower specificity is inappropriate because specificity is the probability of a negative result among patients who do not have the disease and is not changed by population prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower specificity is inappropriate because specificity is the probability of a negative result among patients who do not have the disease and is not changed by population prevalence."
            },
            {
              "id": "B",
              "text": "Option B: Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
            },
            {
              "id": "C",
              "text": "Option C: Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower specificity is inappropriate because specificity is the probability of a negative result among patients who do not have the disease and is not changed by population prevalence."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Higher false-negative rate is inappropriate because the false-negative rate equals 1 minus sensitivity and does not increase merely because the patient belongs to a lower-prevalence population."
            },
            {
              "id": "B",
              "text": "Option B: Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
            },
            {
              "id": "C",
              "text": "Option C: Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Higher false-negative rate is inappropriate because the false-negative rate equals 1 minus sensitivity and does not increase merely because the patient belongs to a lower-prevalence population."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Higher positive predictive value is inappropriate because positive predictive value decreases, not increases, when the same assay is used in a population with lower disease prevalence."
            },
            {
              "id": "B",
              "text": "Option B: Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
            },
            {
              "id": "C",
              "text": "Option C: Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Higher positive predictive value is inappropriate because positive predictive value decreases, not increases, when the same assay is used in a population with lower disease prevalence."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Unchanged positive predictive value is inappropriate because positive predictive value is prevalence dependent. The student\u0027s lower pretest probability produces a lower PPV despite use of the same assay."
            },
            {
              "id": "B",
              "text": "Option B: Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
            },
            {
              "id": "C",
              "text": "Option C: Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Unchanged positive predictive value is inappropriate because positive predictive value is prevalence dependent. The student\u0027s lower pretest probability produces a lower PPV despite use of the same assay."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The false-positive rate equals 1 minus specificity and therefore remains unchanged when specificity and the cutoff are unchanged. False positives may constitute a larger fraction of all positive results, but that is lower PPV, not a higher false-positive rate."
            },
            {
              "id": "B",
              "text": "Option B: Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
            },
            {
              "id": "C",
              "text": "Option C: Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The false-positive rate equals 1 minus specificity and therefore remains unchanged when specificity and the cutoff are unchanged. False positives may constitute a larger fraction of all positive results, but that is lower PPV, not a higher false-positive rate."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower positive likelihood ratio is inappropriate because the positive likelihood ratio is unchanged, not lower, because the assay and cutoff are identical."
            },
            {
              "id": "B",
              "text": "Option B: Lower negative predictive value is inappropriate because negative predictive value increases, rather than decreases, when disease prevalence is lower."
            },
            {
              "id": "C",
              "text": "Option C: Higher sensitivity is inappropriate because sensitivity is the probability of a positive result among patients who truly have the disease and is not changed by population prevalence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower positive likelihood ratio is inappropriate because the positive likelihood ratio is unchanged, not lower, because the assay and cutoff are identical."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-relative-risk-calculation-2146",
      "expectedHashes": {
        "ranaze_step3_uat": "85dae9ea590630b3b1f5d1befa37c86ce794653eeb300c3cef91a2752af5b129",
        "ranaze_step3_prd": "85dae9ea590630b3b1f5d1befa37c86ce794653eeb300c3cef91a2752af5b129"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This is the absolute risk reduction: 0.15 - 0.12 = 0.03, not the relative risk."
            },
            {
              "id": "B",
              "text": "Option B: This is the relative risk reduction: 1 - 0.80 = 0.20."
            },
            {
              "id": "C",
              "text": "Option D: This reverses the comparison by dividing the placebo risk by the treatment risk: 15%/12% = 1.25."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This is the absolute risk reduction: 0.15 - 0.12 = 0.03, not the relative risk."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This is the relative risk reduction: 1 - 0.80 = 0.20."
            },
            {
              "id": "B",
              "text": "Option A: This is the absolute risk reduction: 0.15 - 0.12 = 0.03, not the relative risk."
            },
            {
              "id": "C",
              "text": "Option D: This reverses the comparison by dividing the placebo risk by the treatment risk: 15%/12% = 1.25."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This is the relative risk reduction: 1 - 0.80 = 0.20."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This reverses the comparison by dividing the placebo risk by the treatment risk: 15%/12% = 1.25."
            },
            {
              "id": "B",
              "text": "Option A: This is the absolute risk reduction: 0.15 - 0.12 = 0.03, not the relative risk."
            },
            {
              "id": "C",
              "text": "Option B: This is the relative risk reduction: 1 - 0.80 = 0.20."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This reverses the comparison by dividing the placebo risk by the treatment risk: 15%/12% = 1.25."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "3.00 is inappropriate because this value does not correspond to the relative risk or absolute risk difference in the study."
            },
            {
              "id": "B",
              "text": "Option A: This is the absolute risk reduction: 0.15 - 0.12 = 0.03, not the relative risk."
            },
            {
              "id": "C",
              "text": "Option B: This is the relative risk reduction: 1 - 0.80 = 0.20."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "3.00 is inappropriate because this value does not correspond to the relative risk or absolute risk difference in the study."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This is the hospitalization risk in the monoclonal-antibody group alone. Relative risk requires comparing that risk with the placebo risk: 0.12/0.15 = 0.80."
            },
            {
              "id": "B",
              "text": "Option A: This is the absolute risk reduction: 0.15 - 0.12 = 0.03, not the relative risk."
            },
            {
              "id": "C",
              "text": "Option B: This is the relative risk reduction: 1 - 0.80 = 0.20."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This is the hospitalization risk in the monoclonal-antibody group alone. Relative risk requires comparing that risk with the placebo risk: 0.12/0.15 = 0.80."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This approximates the odds ratio: (0.12/0.88)/(0.15/0.85) \u2248 0.77. The requested relative risk divides the two event probabilities directly and equals 0.80."
            },
            {
              "id": "B",
              "text": "Option A: This is the absolute risk reduction: 0.15 - 0.12 = 0.03, not the relative risk."
            },
            {
              "id": "C",
              "text": "Option B: This is the relative risk reduction: 1 - 0.80 = 0.20."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This approximates the odds ratio: (0.12/0.88)/(0.15/0.85) \u2248 0.77. The requested relative risk divides the two event probabilities directly and equals 0.80."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "This is the unrounded number needed to treat obtained from the 0.03 absolute risk reduction: 1/0.03 \u2248 33.3. It is not the relative risk."
            },
            {
              "id": "B",
              "text": "Option A: This is the absolute risk reduction: 0.15 - 0.12 = 0.03, not the relative risk."
            },
            {
              "id": "C",
              "text": "Option B: This is the relative risk reduction: 1 - 0.80 = 0.20."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "This is the unrounded number needed to treat obtained from the 0.03 absolute risk reduction: 1/0.03 \u2248 33.3. It is not the relative risk."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-relative-risk-confidence-interval-counseling-1186",
      "expectedHashes": {
        "ranaze_step3_uat": "90281baec1d114bbbc15a9c05871b4c2597384d4a72662d0e2bc6e07a6e3fec7",
        "ranaze_step3_prd": "90281baec1d114bbbc15a9c05871b4c2597384d4a72662d0e2bc6e07a6e3fec7"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "B",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            },
            {
              "id": "C",
              "text": "Option D: The study findings are not statistically significant because the confidence interval is relatively wide. is inappropriate because the confidence interval excludes 1.0, so the reported relative risk is statistically significant despite its width."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option D: The study findings are not statistically significant because the confidence interval is relatively wide. is inappropriate because the confidence interval excludes 1.0, so the reported relative risk is statistically significant despite its width."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The study findings are not statistically significant because the confidence interval is relatively wide. is inappropriate because the confidence interval excludes 1.0, so the reported relative risk is statistically significant despite its width."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The study findings are not statistically significant because the confidence interval is relatively wide. is inappropriate because the confidence interval excludes 1.0, so the reported relative risk is statistically significant despite its width."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The study proves that hormone therapy directly causes breast cancer in every population. is inappropriate because an observational association does not prove universal causation, and the magnitude of risk may differ across populations and treatment regimens."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The study proves that hormone therapy directly causes breast cancer in every population. is inappropriate because an observational association does not prove universal causation, and the magnitude of risk may differ across populations and treatment regimens."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The relative risk of 1.4 means that 40% of combined hormone-therapy users will develop breast cancer. is inappropriate because rR 1.4 means that risk among users was 1.4 times the risk among nonusers\u00E2\u20AC\u201Da 40% relative increase. It does not mean that 40% of users developed cancer."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The relative risk of 1.4 means that 40% of combined hormone-therapy users will develop breast cancer. is inappropriate because rR 1.4 means that risk among users was 1.4 times the risk among nonusers\u00E2\u20AC\u201Da 40% relative increase. It does not mean that 40% of users developed cancer."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Combined hormone therapy increases every user\u0027s absolute probability of breast cancer by 40 percentage points. is inappropriate because a 40% relative increase is not a 40-percentage-point absolute increase. The absolute increase cannot be calculated without the baseline event risk among nonusers."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Combined hormone therapy increases every user\u0027s absolute probability of breast cancer by 40 percentage points. is inappropriate because a 40% relative increase is not a 40-percentage-point absolute increase. The absolute increase cannot be calculated without the baseline event risk among nonusers."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The confidence interval of 1.1-1.8 represents an absolute breast cancer risk of 1.1%-1.8% among hormone users. is inappropriate because the values 1.1-1.8 are the confidence limits for a risk ratio, not percentages describing the observed absolute incidence of breast cancer."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The confidence interval of 1.1-1.8 represents an absolute breast cancer risk of 1.1%-1.8% among hormone users. is inappropriate because the values 1.1-1.8 are the confidence limits for a risk ratio, not percentages describing the observed absolute incidence of breast cancer."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Because this was a cohort study, measured and unmeasured confounding have been eliminated. is inappropriate because a cohort study remains observational and can be affected by confounding and selection bias; its design does not eliminate all measured or unmeasured differences between users and nonusers."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Because this was a cohort study, measured and unmeasured confounding have been eliminated. is inappropriate because a cohort study remains observational and can be affected by confounding and selection bias; its design does not eliminate all measured or unmeasured differences between users and nonusers."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The reported relative risk can be applied directly as this patient\u0027s personal absolute risk regardless of her baseline risk. is inappropriate because rR describes a group-level multiplicative association. Translating it into this patient\u0027s absolute risk requires her baseline risk and information about applicability of the study population and regimen."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The reported relative risk can be applied directly as this patient\u0027s personal absolute risk regardless of her baseline risk. is inappropriate because rR describes a group-level multiplicative association. Translating it into this patient\u0027s absolute risk requires her baseline risk and information about applicability of the study population and regimen."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "There is a 95% probability that the true relative risk of breast cancer lies between 1.1 and 1.8. is inappropriate because in frequentist analysis, the true relative risk is fixed; the calculated interval either contains it or does not. The 95% confidence level means that approximately 95% of intervals generated by repeated sampling with the same method would contain the true relative risk."
            },
            {
              "id": "B",
              "text": "Option B: She should avoid hormone therapy because any statistically significant increase in relative risk makes treatment inappropriate. is inappropriate because statistical significance alone does not determine whether a treatment should be used; clinical importance, absolute risk, symptom severity, and patient preferences must also be considered."
            },
            {
              "id": "C",
              "text": "Option C: Her absolute risk of dying from breast cancer is necessarily greater than her risk of osteoporotic fracture. is inappropriate because relative risk data do not establish that this patient\u0027s absolute risk of breast cancer death exceeds her fracture risk."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "There is a 95% probability that the true relative risk of breast cancer lies between 1.1 and 1.8. is inappropriate because in frequentist analysis, the true relative risk is fixed; the calculated interval either contains it or does not. The 95% confidence level means that approximately 95% of intervals generated by repeated sampling with the same method would contain the true relative risk."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-survival-curve-acute-aortic-dissection-1138",
      "expectedHashes": {
        "ranaze_step3_uat": "4a164ca8be0b8e01cd9688de2ac535913043f8d9799083d6bc19b68ffef6d786"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic myeloid leukemia generally produces a more gradual decline in survival over months to years rather than a sharp early decrease."
            },
            {
              "id": "B",
              "text": "Option C: Chronic hepatitis C infection is inappropriate because chronic hepatitis C typically progresses over years or decades, so substantial mortality immediately after diagnosis would not be expected."
            },
            {
              "id": "C",
              "text": "Option D: Type 1 diabetes mellitus is a chronic treatable condition and would not ordinarily cause a steep decline in survival immediately after diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic myeloid leukemia generally produces a more gradual decline in survival over months to years rather than a sharp early decrease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic hepatitis C infection is inappropriate because chronic hepatitis C typically progresses over years or decades, so substantial mortality immediately after diagnosis would not be expected."
            },
            {
              "id": "B",
              "text": "Option B: Chronic myeloid leukemia generally produces a more gradual decline in survival over months to years rather than a sharp early decrease."
            },
            {
              "id": "C",
              "text": "Option D: Type 1 diabetes mellitus is a chronic treatable condition and would not ordinarily cause a steep decline in survival immediately after diagnosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic hepatitis C infection is inappropriate because chronic hepatitis C typically progresses over years or decades, so substantial mortality immediately after diagnosis would not be expected."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Type 1 diabetes mellitus is a chronic treatable condition and would not ordinarily cause a steep decline in survival immediately after diagnosis."
            },
            {
              "id": "B",
              "text": "Option B: Chronic myeloid leukemia generally produces a more gradual decline in survival over months to years rather than a sharp early decrease."
            },
            {
              "id": "C",
              "text": "Option C: Chronic hepatitis C infection is inappropriate because chronic hepatitis C typically progresses over years or decades, so substantial mortality immediately after diagnosis would not be expected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Type 1 diabetes mellitus is a chronic treatable condition and would not ordinarily cause a steep decline in survival immediately after diagnosis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Untreated HIV infection usually causes progressive immune dysfunction over years rather than extreme mortality during the first several days after diagnosis."
            },
            {
              "id": "B",
              "text": "Option B: Chronic myeloid leukemia generally produces a more gradual decline in survival over months to years rather than a sharp early decrease."
            },
            {
              "id": "C",
              "text": "Option C: Chronic hepatitis C infection is inappropriate because chronic hepatitis C typically progresses over years or decades, so substantial mortality immediately after diagnosis would not be expected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Untreated HIV infection usually causes progressive immune dysfunction over years rather than extreme mortality during the first several days after diagnosis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pancreatic adenocarcinoma is inappropriate because pancreatic cancer has poor overall survival, but deaths generally accumulate over months to years rather than clustering in the first several days after diagnosis."
            },
            {
              "id": "B",
              "text": "Option B: Chronic myeloid leukemia generally produces a more gradual decline in survival over months to years rather than a sharp early decrease."
            },
            {
              "id": "C",
              "text": "Option C: Chronic hepatitis C infection is inappropriate because chronic hepatitis C typically progresses over years or decades, so substantial mortality immediately after diagnosis would not be expected."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pancreatic adenocarcinoma is inappropriate because pancreatic cancer has poor overall survival, but deaths generally accumulate over months to years rather than clustering in the first several days after diagnosis."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-test-characteristics-486",
      "expectedHashes": {
        "ranaze_step3_uat": "a6d4f1deed697eaadc4de94bba31508ded2f61cca085644c20fc22afe75e9b3e",
        "ranaze_step3_prd": "a6d4f1deed697eaadc4de94bba31508ded2f61cca085644c20fc22afe75e9b3e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High sensitivity, low specificity, and high positive predictive value is inappropriate because sensitivity is high, but specificity is also high rather than low; positive predictive value is low because false positives outnumber true positives."
            },
            {
              "id": "B",
              "text": "Option C: Low sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity is high, not low, and positive predictive value is only 24.1%."
            },
            {
              "id": "C",
              "text": "Option D: High sensitivity, low specificity, and low positive predictive value is inappropriate because sensitivity and specificity are both high. The low positive predictive value reflects the combination of low prevalence and the remaining false-positive rate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High sensitivity, low specificity, and high positive predictive value is inappropriate because sensitivity is high, but specificity is also high rather than low; positive predictive value is low because false positives outnumber true positives."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity is high, not low, and positive predictive value is only 24.1%."
            },
            {
              "id": "B",
              "text": "Option B: High sensitivity, low specificity, and high positive predictive value is inappropriate because sensitivity is high, but specificity is also high rather than low; positive predictive value is low because false positives outnumber true positives."
            },
            {
              "id": "C",
              "text": "Option D: High sensitivity, low specificity, and low positive predictive value is inappropriate because sensitivity and specificity are both high. The low positive predictive value reflects the combination of low prevalence and the remaining false-positive rate."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity is high, not low, and positive predictive value is only 24.1%."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High sensitivity, low specificity, and low positive predictive value is inappropriate because sensitivity and specificity are both high. The low positive predictive value reflects the combination of low prevalence and the remaining false-positive rate."
            },
            {
              "id": "B",
              "text": "Option B: High sensitivity, low specificity, and high positive predictive value is inappropriate because sensitivity is high, but specificity is also high rather than low; positive predictive value is low because false positives outnumber true positives."
            },
            {
              "id": "C",
              "text": "Option C: Low sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity is high, not low, and positive predictive value is only 24.1%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High sensitivity, low specificity, and low positive predictive value is inappropriate because sensitivity and specificity are both high. The low positive predictive value reflects the combination of low prevalence and the remaining false-positive rate."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low sensitivity, low specificity, and low positive predictive value is inappropriate because neither sensitivity nor specificity is low; only positive predictive value is low."
            },
            {
              "id": "B",
              "text": "Option B: High sensitivity, low specificity, and high positive predictive value is inappropriate because sensitivity is high, but specificity is also high rather than low; positive predictive value is low because false positives outnumber true positives."
            },
            {
              "id": "C",
              "text": "Option C: Low sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity is high, not low, and positive predictive value is only 24.1%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low sensitivity, low specificity, and low positive predictive value is inappropriate because neither sensitivity nor specificity is low; only positive predictive value is low."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low sensitivity, high specificity, and low positive predictive value is inappropriate because sensitivity is not low: 38 of 40 affected participants tested positive, yielding 95% sensitivity. Specificity is high at 93.9%, and positive predictive value is low at 24.1%."
            },
            {
              "id": "B",
              "text": "Option B: High sensitivity, low specificity, and high positive predictive value is inappropriate because sensitivity is high, but specificity is also high rather than low; positive predictive value is low because false positives outnumber true positives."
            },
            {
              "id": "C",
              "text": "Option C: Low sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity is high, not low, and positive predictive value is only 24.1%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low sensitivity, high specificity, and low positive predictive value is inappropriate because sensitivity is not low: 38 of 40 affected participants tested positive, yielding 95% sensitivity. Specificity is high at 93.9%, and positive predictive value is low at 24.1%."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low sensitivity, low specificity, and high positive predictive value is inappropriate because all three classifications are incorrect. Sensitivity is 95%, specificity is 93.9%, and positive predictive value is 24.1%."
            },
            {
              "id": "B",
              "text": "Option B: High sensitivity, low specificity, and high positive predictive value is inappropriate because sensitivity is high, but specificity is also high rather than low; positive predictive value is low because false positives outnumber true positives."
            },
            {
              "id": "C",
              "text": "Option C: Low sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity is high, not low, and positive predictive value is only 24.1%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low sensitivity, low specificity, and high positive predictive value is inappropriate because all three classifications are incorrect. Sensitivity is 95%, specificity is 93.9%, and positive predictive value is 24.1%."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "High sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity and specificity are high, but positive predictive value is low: only 38 of the 158 positive results are true positives, yielding a PPV of 24.1%."
            },
            {
              "id": "B",
              "text": "Option B: High sensitivity, low specificity, and high positive predictive value is inappropriate because sensitivity is high, but specificity is also high rather than low; positive predictive value is low because false positives outnumber true positives."
            },
            {
              "id": "C",
              "text": "Option C: Low sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity is high, not low, and positive predictive value is only 24.1%."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "High sensitivity, high specificity, and high positive predictive value is inappropriate because sensitivity and specificity are high, but positive predictive value is low: only 38 of the 158 positive results are true positives, yielding a PPV of 24.1%."
        }
      }
    },
    {
      "externalId": "step3-biostatistics-vision-screening-test-utility-2374",
      "expectedHashes": {
        "ranaze_step3_uat": "a94ef57218ba716a6c180081046f14cac4ba7f0f4a9d3f98bef0a63f067764c1",
        "ranaze_step3_prd": "a94ef57218ba716a6c180081046f14cac4ba7f0f4a9d3f98bef0a63f067764c1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "B",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            },
            {
              "id": "C",
              "text": "Option D: A correlation coefficient of 0.78 indicates that screening visual acuity and refraction are unrelated is inappropriate because a correlation coefficient of 0.78 indicates a substantial relationship, not an absence of association."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option D: A correlation coefficient of 0.78 indicates that screening visual acuity and refraction are unrelated is inappropriate because a correlation coefficient of 0.78 indicates a substantial relationship, not an absence of association."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A correlation coefficient of 0.78 indicates that screening visual acuity and refraction are unrelated is inappropriate because a correlation coefficient of 0.78 indicates a substantial relationship, not an absence of association."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A correlation coefficient of 0.78 indicates that screening visual acuity and refraction are unrelated is inappropriate because a correlation coefficient of 0.78 indicates a substantial relationship, not an absence of association."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The child does not need further evaluation because visual acuity of 20/70 is only mildly abnormal is inappropriate because distance visual acuity of 20/70 and 20/50 is abnormal and warrants further assessment, particularly after a failed screening test."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The child does not need further evaluation because visual acuity of 20/70 is only mildly abnormal is inappropriate because distance visual acuity of 20/70 and 20/50 is abnormal and warrants further assessment, particularly after a failed screening test."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A sensitivity of 72% means that 28% of failed screenings are false-positive results is inappropriate because one minus sensitivity is the false-negative fraction among children who truly have the condition, not the false-positive fraction among children who fail screening."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A sensitivity of 72% means that 28% of failed screenings are false-positive results is inappropriate because one minus sensitivity is the false-negative fraction among children who truly have the condition, not the false-positive fraction among children who fail screening."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A specificity of 94% means that 94% of children who fail screening have myopia is inappropriate because this interprets specificity as positive predictive value. Specificity is the proportion of unaffected children who pass; the probability of disease after a failed test also depends on prevalence."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A specificity of 94% means that 94% of children who fail screening have myopia is inappropriate because this interprets specificity as positive predictive value. Specificity is the proportion of unaffected children who pass; the probability of disease after a failed test also depends on prevalence."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The high specificity makes a passing result sufficient to rule out a refractive abnormality is inappropriate because high specificity chiefly helps confirm disease when a result is positive. A test with only 72% sensitivity will miss 28% of affected children, so a negative result cannot reliably rule out the condition."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The high specificity makes a passing result sufficient to rule out a refractive abnormality is inappropriate because high specificity chiefly helps confirm disease when a result is positive. A test with only 72% sensitivity will miss 28% of affected children, so a negative result cannot reliably rule out the condition."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The correlation coefficient means the two measurement methods agree exactly in 78% of children is inappropriate because pearson correlation measures the strength and direction of a linear association, not the percentage of observations with exact agreement."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The correlation coefficient means the two measurement methods agree exactly in 78% of children is inappropriate because pearson correlation measures the strength and direction of a linear association, not the percentage of observations with exact agreement."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The correlation coefficient means that screening acuity explains 78% of the variation in formal refraction is inappropriate because in a simple linear relationship, explained variation is represented by r\u00B2. Here, 0.78\u00B2 is approximately 0.61, not 0.78."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The correlation coefficient means that screening acuity explains 78% of the variation in formal refraction is inappropriate because in a simple linear relationship, explained variation is represented by r\u00B2. Here, 0.78\u00B2 is approximately 0.61, not 0.78."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The failed screen definitively diagnoses myopia, so corrective lenses can be prescribed without formal evaluation is inappropriate because a screening result identifies children needing diagnostic evaluation; it does not itself establish myopia or determine the appropriate lens prescription."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The failed screen definitively diagnoses myopia, so corrective lenses can be prescribed without formal evaluation is inappropriate because a screening result identifies children needing diagnostic evaluation; it does not itself establish myopia or determine the appropriate lens prescription."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The bilateral acuity deficits definitively establish amblyopia rather than a refractive error is inappropriate because reduced acuity can result from refractive error, amblyopia, or other ocular disease. Screening acuity alone cannot establish a specific diagnosis."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The bilateral acuity deficits definitively establish amblyopia rather than a refractive error is inappropriate because reduced acuity can result from refractive error, amblyopia, or other ocular disease. Screening acuity alone cannot establish a specific diagnosis."
        },
        "M": {
          "prompt": "Which feature of option M should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Her normal preschool screen effectively excludes a newly developed refractive error is inappropriate because a normal result 4 years earlier does not exclude a subsequently developed abnormality. The study states that myopia prevalence increased with age, and her current acuity is abnormal."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Her normal preschool screen effectively excludes a newly developed refractive error is inappropriate because a normal result 4 years earlier does not exclude a subsequently developed abnormality. The study states that myopia prevalence increased with age, and her current acuity is abnormal."
        },
        "N": {
          "prompt": "Which feature of option N should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The increasing prevalence of myopia with age decreases the positive predictive value of a failed screen is inappropriate because with sensitivity and specificity held constant, increasing disease prevalence generally increases positive predictive value rather than decreasing it."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The increasing prevalence of myopia with age decreases the positive predictive value of a failed screen is inappropriate because with sensitivity and specificity held constant, increasing disease prevalence generally increases positive predictive value rather than decreasing it."
        },
        "O": {
          "prompt": "Which feature of option O should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A screening test with 72% sensitivity is too inaccurate to have any referral value is inappropriate because moderate sensitivity does not eliminate referral utility, particularly when specificity is 94%, correlation with formal refraction is substantial, and untreated failures persisted."
            },
            {
              "id": "B",
              "text": "Option B: The child should wait several years because age-related myopia usually resolves spontaneously is inappropriate because the prevalence of myopia increases with age, and children who failed screening did not later pass without corrective treatment."
            },
            {
              "id": "C",
              "text": "Option C: The screening result is probably false because the test was not administered by an ophthalmologist is inappropriate because the reported performance characteristics demonstrate that screening can be useful even when administered outside a physician\u0027s office."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A screening test with 72% sensitivity is too inaccurate to have any referral value is inappropriate because moderate sensitivity does not eliminate referral utility, particularly when specificity is 94%, correlation with formal refraction is substantial, and untreated failures persisted."
        }
      }
    },
    {
      "externalId": "step3-cardiology-sick-sinus-syndrome-syncope-2057",
      "expectedHashes": {
        "ranaze_step3_uat": "f20c4c82db1093595ef0508ca54b010a2e982d98932d9650fcc892d17e141a2c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "B",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            },
            {
              "id": "C",
              "text": "Option D: Ashman phenomenon is an aberrantly conducted supraventricular beat during atrial fibrillation and does not itself cause recurrent syncope."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option D: Ashman phenomenon is an aberrantly conducted supraventricular beat during atrial fibrillation and does not itself cause recurrent syncope."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ashman phenomenon is an aberrantly conducted supraventricular beat during atrial fibrillation and does not itself cause recurrent syncope."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ashman phenomenon is an aberrantly conducted supraventricular beat during atrial fibrillation and does not itself cause recurrent syncope."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sustained monomorphic ventricular tachycardia is inappropriate because sustained ventricular tachycardia produces a regular wide-complex tachycardia rather than alternating bradycardia and atrial fibrillation with pauses."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sustained monomorphic ventricular tachycardia is inappropriate because sustained ventricular tachycardia produces a regular wide-complex tachycardia rather than alternating bradycardia and atrial fibrillation with pauses."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Orthostatic hypotension is inappropriate because getting out of bed makes orthostatic syncope tempting, but no orthostatic measurements or persistent hypotension are provided. More importantly, the rhythm strip directly shows atrial fibrillation terminating into a prolonged sinus pause, which explains abrupt cerebral hypoperfusion."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Orthostatic hypotension is inappropriate because getting out of bed makes orthostatic syncope tempting, but no orthostatic measurements or persistent hypotension are provided. More importantly, the rhythm strip directly shows atrial fibrillation terminating into a prolonged sinus pause, which explains abrupt cerebral hypoperfusion."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vasovagal syncope usually has a recognizable trigger or autonomic prodrome. This episode was abrupt, and months of alternating palpitations and lightheadedness plus documented tachy-brady physiology support an arrhythmic cause."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vasovagal syncope usually has a recognizable trigger or autonomic prodrome. This episode was abrupt, and months of alternating palpitations and lightheadedness plus documented tachy-brady physiology support an arrhythmic cause."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carotid sinus hypersensitivity may cause syncope in older adults after neck pressure or head turning. No such trigger is described, whereas a prolonged post-tachyarrhythmia sinus pause is directly documented."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carotid sinus hypersensitivity may cause syncope in older adults after neck pressure or head turning. No such trigger is described, whereas a prolonged post-tachyarrhythmia sinus pause is directly documented."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intermittent high-grade atrioventricular block is inappropriate because high-grade AV block can cause abrupt syncope, but the strip identifies a sinus pause after atrial fibrillation terminates rather than ongoing atrial activity with failed ventricular conduction. The alternating tachyarrhythmia and sinus-node pause defines tachy-brady syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intermittent high-grade atrioventricular block is inappropriate because high-grade AV block can cause abrupt syncope, but the strip identifies a sinus pause after atrial fibrillation terminates rather than ongoing atrial activity with failed ventricular conduction. The alternating tachyarrhythmia and sinus-node pause defines tachy-brady syndrome."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Medication-induced sinus node suppression is inappropriate because beta blockers, nondihydropyridine calcium-channel blockers, digoxin, and other drugs can worsen sinus-node dysfunction. She takes amlodipine, a dihydropyridine that does not meaningfully suppress the sinus or AV node, and atorvastatin; therefore medication toxicity does not account for the pattern."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Medication-induced sinus node suppression is inappropriate because beta blockers, nondihydropyridine calcium-channel blockers, digoxin, and other drugs can worsen sinus-node dysfunction. She takes amlodipine, a dihydropyridine that does not meaningfully suppress the sinus or AV node, and atorvastatin; therefore medication toxicity does not account for the pattern."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Severe aortic stenosis generally causes exertional syncope and would usually produce a characteristic systolic murmur. Her cardiac examination instead emphasizes an irregular rhythm, and the rhythm strip provides a direct arrhythmic mechanism."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Severe aortic stenosis generally causes exertional syncope and would usually produce a characteristic systolic murmur. Her cardiac examination instead emphasizes an irregular rhythm, and the rhythm strip provides a direct arrhythmic mechanism."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Generalized tonic-clonic seizure is inappropriate because a seizure is unlikely because the loss of consciousness lasted about 15 seconds and resolved without confusion or tonic-clonic movements. The documented prolonged pause supplies a cardiac explanation."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Generalized tonic-clonic seizure is inappropriate because a seizure is unlikely because the loss of consciousness lasted about 15 seconds and resolved without confusion or tonic-clonic movements. The documented prolonged pause supplies a cardiac explanation."
        },
        "M": {
          "prompt": "Which feature of option M should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A benign physiologic pause after termination of atrial fibrillation is inappropriate because a brief pause can occur after conversion of a tachyarrhythmia, but a prolonged pause associated with syncope and months of tachy-brady symptoms is pathologic sinus-node dysfunction, not a benign physiologic variant."
            },
            {
              "id": "B",
              "text": "Option B: Persistent atrial fibrillation is inappropriate because atrial fibrillation alone rarely causes syncope unless accompanied by severe hemodynamic compromise or prolonged pauses due to sinus node dysfunction."
            },
            {
              "id": "C",
              "text": "Option C: Long QT syndrome predisposes to torsades de pointes and is characterized by QT prolongation rather than atrial fibrillation with sinus pauses."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A benign physiologic pause after termination of atrial fibrillation is inappropriate because a brief pause can occur after conversion of a tachyarrhythmia, but a prolonged pause associated with syncope and months of tachy-brady symptoms is pathologic sinus-node dysfunction, not a benign physiologic variant."
        }
      }
    },
    {
      "externalId": "step3-cardiology-viral-myocarditis-household-transmission-2316",
      "expectedHashes": {
        "ranaze_step3_uat": "3c66383d5f155a5dd562f65a0ebd41a6dd3c1d489bb7d3b110560d2c9a7c89cd",
        "ranaze_step3_prd": "3c66383d5f155a5dd562f65a0ebd41a6dd3c1d489bb7d3b110560d2c9a7c89cd"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An inactivated influenza vaccination received 1 week earlier is inappropriate because inactivated influenza vaccines cannot replicate and are not a source of enterovirus infection."
            },
            {
              "id": "B",
              "text": "Option C: A patient treated during an overnight shift is inappropriate because occupational exposure is possible for many infections, but the stem provides a specific household link to a child with laboratory-confirmed coxsackievirus B infection."
            },
            {
              "id": "C",
              "text": "Option D: Contaminated undercooked poultry is inappropriate because undercooked poultry is associated with infections such as Campylobacter or Salmonella, not the enteroviral myocarditis syndrome described here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An inactivated influenza vaccination received 1 week earlier is inappropriate because inactivated influenza vaccines cannot replicate and are not a source of enterovirus infection."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A patient treated during an overnight shift is inappropriate because occupational exposure is possible for many infections, but the stem provides a specific household link to a child with laboratory-confirmed coxsackievirus B infection."
            },
            {
              "id": "B",
              "text": "Option B: An inactivated influenza vaccination received 1 week earlier is inappropriate because inactivated influenza vaccines cannot replicate and are not a source of enterovirus infection."
            },
            {
              "id": "C",
              "text": "Option D: Contaminated undercooked poultry is inappropriate because undercooked poultry is associated with infections such as Campylobacter or Salmonella, not the enteroviral myocarditis syndrome described here."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A patient treated during an overnight shift is inappropriate because occupational exposure is possible for many infections, but the stem provides a specific household link to a child with laboratory-confirmed coxsackievirus B infection."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contaminated undercooked poultry is inappropriate because undercooked poultry is associated with infections such as Campylobacter or Salmonella, not the enteroviral myocarditis syndrome described here."
            },
            {
              "id": "B",
              "text": "Option B: An inactivated influenza vaccination received 1 week earlier is inappropriate because inactivated influenza vaccines cannot replicate and are not a source of enterovirus infection."
            },
            {
              "id": "C",
              "text": "Option C: A patient treated during an overnight shift is inappropriate because occupational exposure is possible for many infections, but the stem provides a specific household link to a child with laboratory-confirmed coxsackievirus B infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contaminated undercooked poultry is inappropriate because undercooked poultry is associated with infections such as Campylobacter or Salmonella, not the enteroviral myocarditis syndrome described here."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A needlestick injury from a coworker is inappropriate because bloodborne exposure can transmit hepatitis B, hepatitis C, or HIV but does not fit the documented household enterovirus exposure."
            },
            {
              "id": "B",
              "text": "Option B: An inactivated influenza vaccination received 1 week earlier is inappropriate because inactivated influenza vaccines cannot replicate and are not a source of enterovirus infection."
            },
            {
              "id": "C",
              "text": "Option C: A patient treated during an overnight shift is inappropriate because occupational exposure is possible for many infections, but the stem provides a specific household link to a child with laboratory-confirmed coxsackievirus B infection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A needlestick injury from a coworker is inappropriate because bloodborne exposure can transmit hepatitis B, hepatitis C, or HIV but does not fit the documented household enterovirus exposure."
        }
      }
    },
    {
      "externalId": "step3-cardiovascular-abdominal-aortic-aneurysm-ct-608",
      "expectedHashes": {
        "ranaze_step3_uat": "ad39e358c5b387c7e5066c0ec59991abc9da8733bbb90fe9e389d8c3599f2d24",
        "ranaze_step3_prd": "ad39e358c5b387c7e5066c0ec59991abc9da8733bbb90fe9e389d8c3599f2d24"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
            },
            {
              "id": "B",
              "text": "Option C: Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
            },
            {
              "id": "C",
              "text": "Option D: Ventilation-perfusion lung scan is inappropriate because a ventilation-perfusion scan evaluates pulmonary embolism but does not address the likely vascular abnormality responsible for the abdominal pain and bilateral edema."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
            },
            {
              "id": "C",
              "text": "Option D: Ventilation-perfusion lung scan is inappropriate because a ventilation-perfusion scan evaluates pulmonary embolism but does not address the likely vascular abnormality responsible for the abdominal pain and bilateral edema."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ventilation-perfusion lung scan is inappropriate because a ventilation-perfusion scan evaluates pulmonary embolism but does not address the likely vascular abnormality responsible for the abdominal pain and bilateral edema."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
            },
            {
              "id": "C",
              "text": "Option C: Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ventilation-perfusion lung scan is inappropriate because a ventilation-perfusion scan evaluates pulmonary embolism but does not address the likely vascular abnormality responsible for the abdominal pain and bilateral edema."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Renal ultrasonography is useful for hydronephrosis or obstructive uropathy but would not evaluate the suspected abdominal vascular lesion."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
            },
            {
              "id": "C",
              "text": "Option C: Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Renal ultrasonography is useful for hydronephrosis or obstructive uropathy but would not evaluate the suspected abdominal vascular lesion."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Duplex ultrasonography of the abdominal aorta is inappropriate because abdominal ultrasonography is appropriate for AAA screening and surveillance, but this symptomatic patient has findings of an aortocaval fistula or another urgent AAA complication. Ultrasound would not define the fistulous connection, surrounding structures, and iliofemoral anatomy as reliably as CTA."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
            },
            {
              "id": "C",
              "text": "Option C: Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Duplex ultrasonography of the abdominal aorta is inappropriate because abdominal ultrasonography is appropriate for AAA screening and surveillance, but this symptomatic patient has findings of an aortocaval fistula or another urgent AAA complication. Ultrasound would not define the fistulous connection, surrounding structures, and iliofemoral anatomy as reliably as CTA."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Noncontrast CT of the abdomen and pelvis is inappropriate because noncontrast CT can reveal an aneurysm or retroperitoneal hemorrhage, but it cannot adequately characterize arterial and venous contrast flow or define a suspected aortocaval fistula for urgent repair planning."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
            },
            {
              "id": "C",
              "text": "Option C: Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Noncontrast CT of the abdomen and pelvis is inappropriate because noncontrast CT can reveal an aneurysm or retroperitoneal hemorrhage, but it cannot adequately characterize arterial and venous contrast flow or define a suspected aortocaval fistula for urgent repair planning."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contrast-enhanced MR angiography of the abdomen and pelvis is inappropriate because mRA can characterize aortic anatomy and is an alternative in selected patients, but it is generally slower and less available than CTA. No contrast contraindication is given, and this symptomatic, tachycardic patient requires rapid imaging for urgent intervention."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
            },
            {
              "id": "C",
              "text": "Option C: Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contrast-enhanced MR angiography of the abdomen and pelvis is inappropriate because mRA can characterize aortic anatomy and is an alternative in selected patients, but it is generally slower and less available than CTA. No contrast contraindication is given, and this symptomatic, tachycardic patient requires rapid imaging for urgent intervention."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Catheter-based abdominal aortography is inappropriate because catheter aortography is invasive and is not the preferred initial diagnostic examination. Modern CTA provides rapid, noninvasive anatomic mapping and is the reference study for operative or endovascular planning."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because heart failure can cause bilateral leg edema and dyspnea but does not explain the pulsatile abdominal mass, continuous bruit, and flank pain."
            },
            {
              "id": "C",
              "text": "Option C: Duplex ultrasonography of the lower extremity veins is inappropriate because lower-extremity venous duplex ultrasound is appropriate for suspected deep venous thrombosis but would not explain the abdominal findings or identify an aortic pathology."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Catheter-based abdominal aortography is inappropriate because catheter aortography is invasive and is not the preferred initial diagnostic examination. Modern CTA provides rapid, noninvasive anatomic mapping and is the reference study for operative or endovascular planning."
        }
      }
    },
    {
      "externalId": "step3-cardiovascular-recurrent-angina-post-cabg-487",
      "expectedHashes": {
        "ranaze_step3_uat": "558289c492548b471074ffa9791b5f9e08d3c36a207e5c5bce8d6bd6b7b3a4bb",
        "ranaze_step3_prd": "558289c492548b471074ffa9791b5f9e08d3c36a207e5c5bce8d6bd6b7b3a4bb"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exercise myocardial perfusion imaging is inappropriate because stress myocardial perfusion imaging is useful for stable chest pain after CABG when high-risk features are absent, but new ischemic ECG changes warrant direct invasive evaluation."
            },
            {
              "id": "B",
              "text": "Option B: Ambulatory Holter monitoring is inappropriate because holter monitoring evaluates suspected arrhythmias causing palpitations or syncope and does not assess recurrent myocardial ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Transthoracic echocardiography is inappropriate because echocardiography can evaluate ventricular function and wall-motion abnormalities but does not identify graft or coronary artery patency and should not delay definitive evaluation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exercise myocardial perfusion imaging is inappropriate because stress myocardial perfusion imaging is useful for stable chest pain after CABG when high-risk features are absent, but new ischemic ECG changes warrant direct invasive evaluation."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ambulatory Holter monitoring is inappropriate because holter monitoring evaluates suspected arrhythmias causing palpitations or syncope and does not assess recurrent myocardial ischemia."
            },
            {
              "id": "B",
              "text": "Option A: Exercise myocardial perfusion imaging is inappropriate because stress myocardial perfusion imaging is useful for stable chest pain after CABG when high-risk features are absent, but new ischemic ECG changes warrant direct invasive evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Transthoracic echocardiography is inappropriate because echocardiography can evaluate ventricular function and wall-motion abnormalities but does not identify graft or coronary artery patency and should not delay definitive evaluation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ambulatory Holter monitoring is inappropriate because holter monitoring evaluates suspected arrhythmias causing palpitations or syncope and does not assess recurrent myocardial ischemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transthoracic echocardiography is inappropriate because echocardiography can evaluate ventricular function and wall-motion abnormalities but does not identify graft or coronary artery patency and should not delay definitive evaluation."
            },
            {
              "id": "B",
              "text": "Option A: Exercise myocardial perfusion imaging is inappropriate because stress myocardial perfusion imaging is useful for stable chest pain after CABG when high-risk features are absent, but new ischemic ECG changes warrant direct invasive evaluation."
            },
            {
              "id": "C",
              "text": "Option B: Ambulatory Holter monitoring is inappropriate because holter monitoring evaluates suspected arrhythmias causing palpitations or syncope and does not assess recurrent myocardial ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transthoracic echocardiography is inappropriate because echocardiography can evaluate ventricular function and wall-motion abnormalities but does not identify graft or coronary artery patency and should not delay definitive evaluation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Multigated acquisition (MUGA) scan is inappropriate because a MUGA scan measures left ventricular ejection fraction and is not the appropriate diagnostic test for suspected recurrent coronary ischemia."
            },
            {
              "id": "B",
              "text": "Option A: Exercise myocardial perfusion imaging is inappropriate because stress myocardial perfusion imaging is useful for stable chest pain after CABG when high-risk features are absent, but new ischemic ECG changes warrant direct invasive evaluation."
            },
            {
              "id": "C",
              "text": "Option B: Ambulatory Holter monitoring is inappropriate because holter monitoring evaluates suspected arrhythmias causing palpitations or syncope and does not assess recurrent myocardial ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Multigated acquisition (MUGA) scan is inappropriate because a MUGA scan measures left ventricular ejection fraction and is not the appropriate diagnostic test for suspected recurrent coronary ischemia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exercise treadmill electrocardiography without imaging is inappropriate because exercise ECG alone is poorly suited to a patient whose baseline tracing already has ST-segment and T-wave abnormalities. More importantly, noninvasive exercise testing should not delay an invasive assessment of this high-risk post-CABG presentation."
            },
            {
              "id": "B",
              "text": "Option A: Exercise myocardial perfusion imaging is inappropriate because stress myocardial perfusion imaging is useful for stable chest pain after CABG when high-risk features are absent, but new ischemic ECG changes warrant direct invasive evaluation."
            },
            {
              "id": "C",
              "text": "Option B: Ambulatory Holter monitoring is inappropriate because holter monitoring evaluates suspected arrhythmias causing palpitations or syncope and does not assess recurrent myocardial ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exercise treadmill electrocardiography without imaging is inappropriate because exercise ECG alone is poorly suited to a patient whose baseline tracing already has ST-segment and T-wave abnormalities. More importantly, noninvasive exercise testing should not delay an invasive assessment of this high-risk post-CABG presentation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Discontinue aspirin and begin clopidogrel monotherapy is inappropriate because replacing aspirin with clopidogrel monotherapy neither evaluates the new ischemia nor matches standard antiplatelet strategy in a patient without aspirin intolerance. If this represents NSTE-ACS, contemporary guidance generally uses aspirin plus a P2Y12 inhibitor when appropriate rather than an unindicated substitution that delays angiography."
            },
            {
              "id": "B",
              "text": "Option A: Exercise myocardial perfusion imaging is inappropriate because stress myocardial perfusion imaging is useful for stable chest pain after CABG when high-risk features are absent, but new ischemic ECG changes warrant direct invasive evaluation."
            },
            {
              "id": "C",
              "text": "Option B: Ambulatory Holter monitoring is inappropriate because holter monitoring evaluates suspected arrhythmias causing palpitations or syncope and does not assess recurrent myocardial ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Discontinue aspirin and begin clopidogrel monotherapy is inappropriate because replacing aspirin with clopidogrel monotherapy neither evaluates the new ischemia nor matches standard antiplatelet strategy in a patient without aspirin intolerance. If this represents NSTE-ACS, contemporary guidance generally uses aspirin plus a P2Y12 inhibitor when appropriate rather than an unindicated substitution that delays angiography."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform serial troponin measurements and reserve angiography only for biomarker elevation is inappropriate because troponin is useful for detecting infarction, but ischemia without biomarker release can still represent unstable angina. Angiography should not be conditioned solely on a later positive troponin when the ECG already shows new ischemic changes."
            },
            {
              "id": "B",
              "text": "Option A: Exercise myocardial perfusion imaging is inappropriate because stress myocardial perfusion imaging is useful for stable chest pain after CABG when high-risk features are absent, but new ischemic ECG changes warrant direct invasive evaluation."
            },
            {
              "id": "C",
              "text": "Option B: Ambulatory Holter monitoring is inappropriate because holter monitoring evaluates suspected arrhythmias causing palpitations or syncope and does not assess recurrent myocardial ischemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform serial troponin measurements and reserve angiography only for biomarker elevation is inappropriate because troponin is useful for detecting infarction, but ischemia without biomarker release can still represent unstable angina. Angiography should not be conditioned solely on a later positive troponin when the ECG already shows new ischemic changes."
        }
      }
    },
    {
      "externalId": "step3-congenital-hypothyroidism-adoptedinfant-038",
      "expectedHashes": {
        "ranaze_step3_uat": "bd1795501dea9d1b033931c19b9963e8aadbcb9b3550a8bd515ed596b5c5dcd3",
        "ranaze_step3_prd": "bd1795501dea9d1b033931c19b9963e8aadbcb9b3550a8bd515ed596b5c5dcd3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "B",
              "text": "Option C: Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            },
            {
              "id": "C",
              "text": "Option D: Obtain cranial ultrasonography to evaluate the enlarged fontanelle is inappropriate because a large anterior fontanelle is a recognized manifestation of congenital hypothyroidism and does not require cranial imaging without signs of increased intracranial pressure or another neurologic indication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            },
            {
              "id": "B",
              "text": "Option B: Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "C",
              "text": "Option D: Obtain cranial ultrasonography to evaluate the enlarged fontanelle is inappropriate because a large anterior fontanelle is a recognized manifestation of congenital hypothyroidism and does not require cranial imaging without signs of increased intracranial pressure or another neurologic indication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain cranial ultrasonography to evaluate the enlarged fontanelle is inappropriate because a large anterior fontanelle is a recognized manifestation of congenital hypothyroidism and does not require cranial imaging without signs of increased intracranial pressure or another neurologic indication."
            },
            {
              "id": "B",
              "text": "Option B: Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "C",
              "text": "Option C: Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain cranial ultrasonography to evaluate the enlarged fontanelle is inappropriate because a large anterior fontanelle is a recognized manifestation of congenital hypothyroidism and does not require cranial imaging without signs of increased intracranial pressure or another neurologic indication."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform renal ultrasonography to evaluate for associated congenital anomalies is inappropriate because routine renal imaging is not part of the initial management of isolated congenital hypothyroidism."
            },
            {
              "id": "B",
              "text": "Option B: Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "C",
              "text": "Option C: Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform renal ultrasonography to evaluate for associated congenital anomalies is inappropriate because routine renal imaging is not part of the initial management of isolated congenital hypothyroidism."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat serum TSH and free T4 in 1 week before beginning treatment is inappropriate because tSH 185 mIU/L with free T4 0.2 ng/dL establishes severe overt primary hypothyroidism. Repeating already diagnostic tests before treatment would cause harmful delay during a critical period of brain development."
            },
            {
              "id": "B",
              "text": "Option B: Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "C",
              "text": "Option C: Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat serum TSH and free T4 in 1 week before beginning treatment is inappropriate because tSH 185 mIU/L with free T4 0.2 ng/dL establishes severe overt primary hypothyroidism. Repeating already diagnostic tests before treatment would cause harmful delay during a critical period of brain development."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain thyroid ultrasonography and radionuclide scintigraphy before starting medication is inappropriate because thyroid imaging may identify dysgenesis, ectopia, or dyshormonogenesis, but consensus guidance recommends starting levothyroxine before imaging. Etiologic testing must never delay replacement."
            },
            {
              "id": "B",
              "text": "Option B: Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "C",
              "text": "Option C: Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain thyroid ultrasonography and radionuclide scintigraphy before starting medication is inappropriate because thyroid imaging may identify dysgenesis, ectopia, or dyshormonogenesis, but consensus guidance recommends starting levothyroxine before imaging. Etiologic testing must never delay replacement."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin iodine supplementation instead of thyroid hormone replacement is inappropriate because iodine cannot substitute for thyroid hormone in severe congenital hypothyroidism and excess iodine can itself impair infant thyroid function. The infant needs immediate levothyroxine."
            },
            {
              "id": "B",
              "text": "Option B: Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "C",
              "text": "Option C: Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin iodine supplementation instead of thyroid hormone replacement is inappropriate because iodine cannot substitute for thyroid hormone in severe congenital hypothyroidism and excess iodine can itself impair infant thyroid function. The infant needs immediate levothyroxine."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start low-dose levothyroxine and titrate slowly over several months is inappropriate because slow adult-style titration is inappropriate in severe congenital hypothyroidism. Infants with very low free T4 should receive a full high starting dose promptly to normalize thyroid hormone and protect neurodevelopment."
            },
            {
              "id": "B",
              "text": "Option B: Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "C",
              "text": "Option C: Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start low-dose levothyroxine and titrate slowly over several months is inappropriate because slow adult-style titration is inappropriate in severe congenital hypothyroidism. Infants with very low free T4 should receive a full high starting dose promptly to normalize thyroid hormone and protect neurodevelopment."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Admit to intensive care for intravenous levothyroxine treatment is inappropriate because oral levothyroxine is standard. Intravenous therapy and intensive care are reserved for patients unable to take enteral medication or with myxedema coma; this infant has stable pulse, respirations, and blood pressure and is feeding, although slowly."
            },
            {
              "id": "B",
              "text": "Option B: Obtain magnetic resonance imaging of the hypothalamic-pituitary region before treatment is inappropriate because the markedly elevated TSH establishes primary rather than central hypothyroidism; pituitary MRI is not the priority and must not delay thyroid hormone replacement."
            },
            {
              "id": "C",
              "text": "Option C: Refer for developmental therapy without thyroid hormone replacement is inappropriate because developmental services are appropriate adjuncts after delayed diagnosis but do not correct the underlying thyroid hormone deficiency."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Admit to intensive care for intravenous levothyroxine treatment is inappropriate because oral levothyroxine is standard. Intravenous therapy and intensive care are reserved for patients unable to take enteral medication or with myxedema coma; this infant has stable pulse, respirations, and blood pressure and is feeding, although slowly."
        }
      }
    },
    {
      "externalId": "step3-derm-psoriasis-arthritis-001",
      "expectedHashes": {
        "ranaze_step3_uat": "0c3d801fea23375b4c6fb33423745be72e4ed75a46d334681347d5d536403e5d",
        "ranaze_step3_prd": "0c3d801fea23375b4c6fb33423745be72e4ed75a46d334681347d5d536403e5d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Greasy yellow scales over erythematous patches is inappropriate because seborrheic dermatitis produces greasy yellow scaling in sebaceous areas such as the scalp, eyebrows, and nasolabial folds and is not associated with distal interphalangeal arthritis."
            },
            {
              "id": "B",
              "text": "Option C: Clusters of tense fluid-filled bullae on an erythematous base is inappropriate because bullous pemphigoid causes tense bullae, usually in older adults, rather than chronic scaly plaques."
            },
            {
              "id": "C",
              "text": "Option D: Pruritic grouped vesicles with excoriations is inappropriate because dermatitis herpetiformis causes intensely pruritic grouped vesicles, typically associated with celiac disease rather than inflammatory arthritis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Greasy yellow scales over erythematous patches is inappropriate because seborrheic dermatitis produces greasy yellow scaling in sebaceous areas such as the scalp, eyebrows, and nasolabial folds and is not associated with distal interphalangeal arthritis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Clusters of tense fluid-filled bullae on an erythematous base is inappropriate because bullous pemphigoid causes tense bullae, usually in older adults, rather than chronic scaly plaques."
            },
            {
              "id": "B",
              "text": "Option B: Greasy yellow scales over erythematous patches is inappropriate because seborrheic dermatitis produces greasy yellow scaling in sebaceous areas such as the scalp, eyebrows, and nasolabial folds and is not associated with distal interphalangeal arthritis."
            },
            {
              "id": "C",
              "text": "Option D: Pruritic grouped vesicles with excoriations is inappropriate because dermatitis herpetiformis causes intensely pruritic grouped vesicles, typically associated with celiac disease rather than inflammatory arthritis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Clusters of tense fluid-filled bullae on an erythematous base is inappropriate because bullous pemphigoid causes tense bullae, usually in older adults, rather than chronic scaly plaques."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pruritic grouped vesicles with excoriations is inappropriate because dermatitis herpetiformis causes intensely pruritic grouped vesicles, typically associated with celiac disease rather than inflammatory arthritis."
            },
            {
              "id": "B",
              "text": "Option B: Greasy yellow scales over erythematous patches is inappropriate because seborrheic dermatitis produces greasy yellow scaling in sebaceous areas such as the scalp, eyebrows, and nasolabial folds and is not associated with distal interphalangeal arthritis."
            },
            {
              "id": "C",
              "text": "Option C: Clusters of tense fluid-filled bullae on an erythematous base is inappropriate because bullous pemphigoid causes tense bullae, usually in older adults, rather than chronic scaly plaques."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pruritic grouped vesicles with excoriations is inappropriate because dermatitis herpetiformis causes intensely pruritic grouped vesicles, typically associated with celiac disease rather than inflammatory arthritis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Violaceous polygonal papules with fine white reticular lines is inappropriate because lichen planus presents with pruritic, violaceous, polygonal papules and Wickham striae rather than silvery plaques."
            },
            {
              "id": "B",
              "text": "Option B: Greasy yellow scales over erythematous patches is inappropriate because seborrheic dermatitis produces greasy yellow scaling in sebaceous areas such as the scalp, eyebrows, and nasolabial folds and is not associated with distal interphalangeal arthritis."
            },
            {
              "id": "C",
              "text": "Option C: Clusters of tense fluid-filled bullae on an erythematous base is inappropriate because bullous pemphigoid causes tense bullae, usually in older adults, rather than chronic scaly plaques."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Violaceous polygonal papules with fine white reticular lines is inappropriate because lichen planus presents with pruritic, violaceous, polygonal papules and Wickham striae rather than silvery plaques."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Annular erythematous plaques with a raised scaly border and central clearing is inappropriate because this describes tinea corporis. Dermatophyte infection can be pruritic and scaly, but its annular advancing border and central clearing do not match psoriasis accompanied by nail pitting and distal inflammatory arthritis."
            },
            {
              "id": "B",
              "text": "Option B: Greasy yellow scales over erythematous patches is inappropriate because seborrheic dermatitis produces greasy yellow scaling in sebaceous areas such as the scalp, eyebrows, and nasolabial folds and is not associated with distal interphalangeal arthritis."
            },
            {
              "id": "C",
              "text": "Option C: Clusters of tense fluid-filled bullae on an erythematous base is inappropriate because bullous pemphigoid causes tense bullae, usually in older adults, rather than chronic scaly plaques."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Annular erythematous plaques with a raised scaly border and central clearing is inappropriate because this describes tinea corporis. Dermatophyte infection can be pruritic and scaly, but its annular advancing border and central clearing do not match psoriasis accompanied by nail pitting and distal inflammatory arthritis."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intensely pruritic, coin-shaped plaques with scale and crust is inappropriate because nummular dermatitis produces intensely pruritic, round or oval, often crusted or scaly plaques, commonly on the extremities. It does not explain the psoriasis-specific combination of nail pitting and distal finger-joint inflammation."
            },
            {
              "id": "B",
              "text": "Option B: Greasy yellow scales over erythematous patches is inappropriate because seborrheic dermatitis produces greasy yellow scaling in sebaceous areas such as the scalp, eyebrows, and nasolabial folds and is not associated with distal interphalangeal arthritis."
            },
            {
              "id": "C",
              "text": "Option C: Clusters of tense fluid-filled bullae on an erythematous base is inappropriate because bullous pemphigoid causes tense bullae, usually in older adults, rather than chronic scaly plaques."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intensely pruritic, coin-shaped plaques with scale and crust is inappropriate because nummular dermatitis produces intensely pruritic, round or oval, often crusted or scaly plaques, commonly on the extremities. It does not explain the psoriasis-specific combination of nail pitting and distal finger-joint inflammation."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Poorly demarcated, excoriated, lichenified plaques in flexural areas is inappropriate because chronic atopic dermatitis can produce pruritic, excoriated, lichenified skin, with flexural involvement typical in older patients. This morphology and distribution are less consistent with sharply demarcated extensor and scalp plaques, and atopic dermatitis does not account for nail pitting with distal inflammatory arthritis."
            },
            {
              "id": "B",
              "text": "Option B: Greasy yellow scales over erythematous patches is inappropriate because seborrheic dermatitis produces greasy yellow scaling in sebaceous areas such as the scalp, eyebrows, and nasolabial folds and is not associated with distal interphalangeal arthritis."
            },
            {
              "id": "C",
              "text": "Option C: Clusters of tense fluid-filled bullae on an erythematous base is inappropriate because bullous pemphigoid causes tense bullae, usually in older adults, rather than chronic scaly plaques."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Poorly demarcated, excoriated, lichenified plaques in flexural areas is inappropriate because chronic atopic dermatitis can produce pruritic, excoriated, lichenified skin, with flexural involvement typical in older patients. This morphology and distribution are less consistent with sharply demarcated extensor and scalp plaques, and atopic dermatitis does not account for nail pitting with distal inflammatory arthritis."
        }
      }
    },
    {
      "externalId": "step3-dermatology-seborrheic-dermatitis-distribution-2489",
      "expectedHashes": {
        "ranaze_step3_uat": "e4893f8d9b99c97713546d47832d568efa3eaaa0def59c5dcf88de090b3d178e",
        "ranaze_step3_prd": "e4893f8d9b99c97713546d47832d568efa3eaaa0def59c5dcf88de090b3d178e"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serpiginous burrows between the fingers is inappropriate because burrows in the interdigital spaces suggest scabies, which typically causes intense pruritus and involves the wrists, finger webs, waistline, and genital region."
            },
            {
              "id": "B",
              "text": "Option C: Honey-colored crusted erosions around the mouth is inappropriate because honey-colored crusts suggest impetigo, a superficial bacterial infection that usually causes localized erosions rather than symmetric greasy scale in sebaceous areas."
            },
            {
              "id": "C",
              "text": "Option D: Thick hyperkeratotic plaques with painful fissures on the palms is inappropriate because hyperkeratosis with fissuring is more consistent with chronic hand dermatitis or palmoplantar keratoderma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serpiginous burrows between the fingers is inappropriate because burrows in the interdigital spaces suggest scabies, which typically causes intense pruritus and involves the wrists, finger webs, waistline, and genital region."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Honey-colored crusted erosions around the mouth is inappropriate because honey-colored crusts suggest impetigo, a superficial bacterial infection that usually causes localized erosions rather than symmetric greasy scale in sebaceous areas."
            },
            {
              "id": "B",
              "text": "Option B: Serpiginous burrows between the fingers is inappropriate because burrows in the interdigital spaces suggest scabies, which typically causes intense pruritus and involves the wrists, finger webs, waistline, and genital region."
            },
            {
              "id": "C",
              "text": "Option D: Thick hyperkeratotic plaques with painful fissures on the palms is inappropriate because hyperkeratosis with fissuring is more consistent with chronic hand dermatitis or palmoplantar keratoderma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Honey-colored crusted erosions around the mouth is inappropriate because honey-colored crusts suggest impetigo, a superficial bacterial infection that usually causes localized erosions rather than symmetric greasy scale in sebaceous areas."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thick hyperkeratotic plaques with painful fissures on the palms is inappropriate because hyperkeratosis with fissuring is more consistent with chronic hand dermatitis or palmoplantar keratoderma."
            },
            {
              "id": "B",
              "text": "Option B: Serpiginous burrows between the fingers is inappropriate because burrows in the interdigital spaces suggest scabies, which typically causes intense pruritus and involves the wrists, finger webs, waistline, and genital region."
            },
            {
              "id": "C",
              "text": "Option C: Honey-colored crusted erosions around the mouth is inappropriate because honey-colored crusts suggest impetigo, a superficial bacterial infection that usually causes localized erosions rather than symmetric greasy scale in sebaceous areas."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thick hyperkeratotic plaques with painful fissures on the palms is inappropriate because hyperkeratosis with fissuring is more consistent with chronic hand dermatitis or palmoplantar keratoderma."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Facial telangiectasias with pustules over the nose and cheeks is inappropriate because central facial telangiectasias and pustules suggest rosacea, which typically spares the scalp and does not cause greasy scale behind the ears or on the sternum."
            },
            {
              "id": "B",
              "text": "Option B: Serpiginous burrows between the fingers is inappropriate because burrows in the interdigital spaces suggest scabies, which typically causes intense pruritus and involves the wrists, finger webs, waistline, and genital region."
            },
            {
              "id": "C",
              "text": "Option C: Honey-colored crusted erosions around the mouth is inappropriate because honey-colored crusts suggest impetigo, a superficial bacterial infection that usually causes localized erosions rather than symmetric greasy scale in sebaceous areas."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Facial telangiectasias with pustules over the nose and cheeks is inappropriate because central facial telangiectasias and pustules suggest rosacea, which typically spares the scalp and does not cause greasy scale behind the ears or on the sternum."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Well-demarcated plaques with silvery scale over the elbows and knees is inappropriate because silvery, sharply demarcated plaques on extensor surfaces suggest plaque psoriasis. Seborrheic dermatitis instead produces thinner, often greasy scale in sebaceous areas such as the scalp, eyebrows, nasolabial folds, ears, and chest."
            },
            {
              "id": "B",
              "text": "Option B: Serpiginous burrows between the fingers is inappropriate because burrows in the interdigital spaces suggest scabies, which typically causes intense pruritus and involves the wrists, finger webs, waistline, and genital region."
            },
            {
              "id": "C",
              "text": "Option C: Honey-colored crusted erosions around the mouth is inappropriate because honey-colored crusts suggest impetigo, a superficial bacterial infection that usually causes localized erosions rather than symmetric greasy scale in sebaceous areas."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Well-demarcated plaques with silvery scale over the elbows and knees is inappropriate because silvery, sharply demarcated plaques on extensor surfaces suggest plaque psoriasis. Seborrheic dermatitis instead produces thinner, often greasy scale in sebaceous areas such as the scalp, eyebrows, nasolabial folds, ears, and chest."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An annular facial plaque with a raised scaly border and central clearing is inappropriate because an annular plaque with an advancing scaly border and central clearing suggests dermatophytosis. This patient\u2019s symmetric greasy scale across several sebaceous regions is characteristic of seborrheic dermatitis."
            },
            {
              "id": "B",
              "text": "Option B: Serpiginous burrows between the fingers is inappropriate because burrows in the interdigital spaces suggest scabies, which typically causes intense pruritus and involves the wrists, finger webs, waistline, and genital region."
            },
            {
              "id": "C",
              "text": "Option C: Honey-colored crusted erosions around the mouth is inappropriate because honey-colored crusts suggest impetigo, a superficial bacterial infection that usually causes localized erosions rather than symmetric greasy scale in sebaceous areas."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An annular facial plaque with a raised scaly border and central clearing is inappropriate because an annular plaque with an advancing scaly border and central clearing suggests dermatophytosis. This patient\u2019s symmetric greasy scale across several sebaceous regions is characteristic of seborrheic dermatitis."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intensely pruritic lichenified plaques in the antecubital and popliteal fossae is inappropriate because marked pruritus, lichenification, and flexural involvement suggest atopic dermatitis. The greasy scale and sebaceous distribution in this older man instead support seborrheic dermatitis."
            },
            {
              "id": "B",
              "text": "Option B: Serpiginous burrows between the fingers is inappropriate because burrows in the interdigital spaces suggest scabies, which typically causes intense pruritus and involves the wrists, finger webs, waistline, and genital region."
            },
            {
              "id": "C",
              "text": "Option C: Honey-colored crusted erosions around the mouth is inappropriate because honey-colored crusts suggest impetigo, a superficial bacterial infection that usually causes localized erosions rather than symmetric greasy scale in sebaceous areas."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intensely pruritic lichenified plaques in the antecubital and popliteal fossae is inappropriate because marked pruritus, lichenification, and flexural involvement suggest atopic dermatitis. The greasy scale and sebaceous distribution in this older man instead support seborrheic dermatitis."
        }
      }
    },
    {
      "externalId": "step3-endocrine-diabetic-nephropathy-401",
      "expectedHashes": {
        "ranaze_step3_uat": "a008930594826631919865d2d19c82dca0844685998a0fda46cbbd5097332689",
        "ranaze_step3_prd": "a008930594826631919865d2d19c82dca0844685998a0fda46cbbd5097332689"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
            },
            {
              "id": "B",
              "text": "Option C: Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
            },
            {
              "id": "C",
              "text": "Option D: Begin aspirin therapy is inappropriate because aspirin is not routinely indicated for primary prevention solely because diabetes and albuminuria are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
            },
            {
              "id": "B",
              "text": "Option B: Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
            },
            {
              "id": "C",
              "text": "Option D: Begin aspirin therapy is inappropriate because aspirin is not routinely indicated for primary prevention solely because diabetes and albuminuria are present."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin aspirin therapy is inappropriate because aspirin is not routinely indicated for primary prevention solely because diabetes and albuminuria are present."
            },
            {
              "id": "B",
              "text": "Option B: Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
            },
            {
              "id": "C",
              "text": "Option C: Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin aspirin therapy is inappropriate because aspirin is not routinely indicated for primary prevention solely because diabetes and albuminuria are present."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "No additional pharmacotherapy is indicated is inappropriate because confirmed hypertension requires treatment, and an ACE inhibitor or ARB is preferred when diabetes and albuminuria coexist."
            },
            {
              "id": "B",
              "text": "Option B: Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
            },
            {
              "id": "C",
              "text": "Option C: Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "No additional pharmacotherapy is indicated is inappropriate because confirmed hypertension requires treatment, and an ACE inhibitor or ARB is preferred when diabetes and albuminuria coexist."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin amlodipine therapy is inappropriate because amlodipine can lower blood pressure but does not replace renin-angiotensin system blockade in a patient with diabetes, hypertension, and albuminuria. An ACE inhibitor or ARB is the recommended initial antihypertensive class in this setting."
            },
            {
              "id": "B",
              "text": "Option B: Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
            },
            {
              "id": "C",
              "text": "Option C: Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin amlodipine therapy is inappropriate because amlodipine can lower blood pressure but does not replace renin-angiotensin system blockade in a patient with diabetes, hypertension, and albuminuria. An ACE inhibitor or ARB is the recommended initial antihypertensive class in this setting."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin chlorthalidone therapy is inappropriate because a thiazide-like diuretic is an effective antihypertensive and may later be added if needed, but it lacks the specific recommendation given to an ACE inhibitor or ARB for diabetic hypertension with albuminuria."
            },
            {
              "id": "B",
              "text": "Option B: Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
            },
            {
              "id": "C",
              "text": "Option C: Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin chlorthalidone therapy is inappropriate because a thiazide-like diuretic is an effective antihypertensive and may later be added if needed, but it lacks the specific recommendation given to an ACE inhibitor or ARB for diabetic hypertension with albuminuria."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer antihypertensive medication until repeat testing confirms albuminuria is inappropriate because albuminuria should be confirmed, but the need to treat hypertension does not depend on that repeat result. He already has elevated blood pressure documented on three occasions; the current albuminuria makes an ACE inhibitor or ARB the preferred initial drug."
            },
            {
              "id": "B",
              "text": "Option B: Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
            },
            {
              "id": "C",
              "text": "Option C: Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer antihypertensive medication until repeat testing confirms albuminuria is inappropriate because albuminuria should be confirmed, but the need to treat hypertension does not depend on that repeat result. He already has elevated blood pressure documented on three occasions; the current albuminuria makes an ACE inhibitor or ARB the preferred initial drug."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin aliskiren therapy is inappropriate because a direct renin inhibitor is not the recommended substitute for an ACE inhibitor or ARB in diabetic hypertension with albuminuria. Current standards specifically favor an ACE inhibitor or ARB because of their demonstrated kidney and cardiovascular benefits."
            },
            {
              "id": "B",
              "text": "Option B: Begin metoprolol therapy is inappropriate because beta-blockers do not provide the same evidence-based kidney protection and are not preferred first-line therapy for hypertension with diabetic albuminuria without another indication."
            },
            {
              "id": "C",
              "text": "Option C: Increase atorvastatin to high-intensity dosing solely because of albuminuria is inappropriate because statin intensity is selected according to overall cardiovascular risk rather than escalated solely because of one albuminuria measurement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin aliskiren therapy is inappropriate because a direct renin inhibitor is not the recommended substitute for an ACE inhibitor or ARB in diabetic hypertension with albuminuria. Current standards specifically favor an ACE inhibitor or ARB because of their demonstrated kidney and cardiovascular benefits."
        }
      }
    },
    {
      "externalId": "step3-endocrine-hyponatremia-osmolality-3247",
      "expectedHashes": {
        "ranaze_step3_uat": "5d02f7bf294fa2ff067f92ab63de2124c11e567fe91e6e0c0b320aacfe062f37",
        "ranaze_step3_prd": "5d02f7bf294fa2ff067f92ab63de2124c11e567fe91e6e0c0b320aacfe062f37"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
            },
            {
              "id": "B",
              "text": "Option C: Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
            },
            {
              "id": "C",
              "text": "Option D: Measure the fractional excretion of sodium is inappropriate because fractional excretion of sodium may help evaluate kidney perfusion or acute kidney injury, but diuretic therapy reduces its reliability and it does not replace serum and urine osmolality in the initial evaluation of hyponatremia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
            },
            {
              "id": "B",
              "text": "Option B: Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
            },
            {
              "id": "C",
              "text": "Option D: Measure the fractional excretion of sodium is inappropriate because fractional excretion of sodium may help evaluate kidney perfusion or acute kidney injury, but diuretic therapy reduces its reliability and it does not replace serum and urine osmolality in the initial evaluation of hyponatremia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure the fractional excretion of sodium is inappropriate because fractional excretion of sodium may help evaluate kidney perfusion or acute kidney injury, but diuretic therapy reduces its reliability and it does not replace serum and urine osmolality in the initial evaluation of hyponatremia."
            },
            {
              "id": "B",
              "text": "Option B: Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
            },
            {
              "id": "C",
              "text": "Option C: Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure the fractional excretion of sodium is inappropriate because fractional excretion of sodium may help evaluate kidney perfusion or acute kidney injury, but diuretic therapy reduces its reliability and it does not replace serum and urine osmolality in the initial evaluation of hyponatremia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure serum thyroid-stimulating hormone concentration alone is inappropriate because hypothyroidism can cause hyponatremia, but thyroid testing alone does not determine tonicity or antidiuretic hormone activity and is not the best initial study."
            },
            {
              "id": "B",
              "text": "Option B: Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
            },
            {
              "id": "C",
              "text": "Option C: Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure serum thyroid-stimulating hormone concentration alone is inappropriate because hypothyroidism can cause hyponatremia, but thyroid testing alone does not determine tonicity or antidiuretic hormone activity and is not the best initial study."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure spot urine sodium and urine chloride concentrations alone is inappropriate because urine electrolytes can help classify hypotonic hyponatremia after urine concentration is assessed, but values are harder to interpret during furosemide therapy and do not establish serum tonicity or antidiuretic activity by themselves."
            },
            {
              "id": "B",
              "text": "Option B: Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
            },
            {
              "id": "C",
              "text": "Option C: Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure spot urine sodium and urine chloride concentrations alone is inappropriate because urine electrolytes can help classify hypotonic hyponatremia after urine concentration is assessed, but values are harder to interpret during furosemide therapy and do not establish serum tonicity or antidiuretic activity by themselves."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure plasma vasopressin concentration is inappropriate because plasma vasopressin is technically difficult to interpret and is not recommended for confirming SIAD. Multiple nonosmotic stimuli in this patient could elevate it regardless of the principal cause."
            },
            {
              "id": "B",
              "text": "Option B: Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
            },
            {
              "id": "C",
              "text": "Option C: Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure plasma vasopressin concentration is inappropriate because plasma vasopressin is technically difficult to interpret and is not recommended for confirming SIAD. Multiple nonosmotic stimuli in this patient could elevate it regardless of the principal cause."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure B-type natriuretic peptide and obtain transthoracic echocardiography is inappropriate because heart-failure assessment may identify one contributor, but it cannot distinguish hypotonic from nonhypotonic hyponatremia or determine whether antidiuretic hormone is appropriately suppressed. The examination also lacks overt venous congestion."
            },
            {
              "id": "B",
              "text": "Option B: Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
            },
            {
              "id": "C",
              "text": "Option C: Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure B-type natriuretic peptide and obtain transthoracic echocardiography is inappropriate because heart-failure assessment may identify one contributor, but it cannot distinguish hypotonic from nonhypotonic hyponatremia or determine whether antidiuretic hormone is appropriately suppressed. The examination also lacks overt venous congestion."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a Legionella urinary antigen test is inappropriate because legionella can cause pneumonia accompanied by hyponatremia, but identifying a pneumonia pathogen would not distinguish pneumonia-associated SIAD from heart-failure- or diuretic-related hyponatremia."
            },
            {
              "id": "B",
              "text": "Option B: Measure hemoglobin A1c concentration is inappropriate because hemoglobin A1c reflects chronic glycemic control but does not classify the current hyponatremia; the serum glucose is only mildly elevated."
            },
            {
              "id": "C",
              "text": "Option C: Perform an adrenocorticotropic hormone stimulation test is inappropriate because an ACTH stimulation test evaluates adrenal insufficiency but is not the first study before confirming hypotonic hyponatremia and assessing urine concentration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a Legionella urinary antigen test is inappropriate because legionella can cause pneumonia accompanied by hyponatremia, but identifying a pneumonia pathogen would not distinguish pneumonia-associated SIAD from heart-failure- or diuretic-related hyponatremia."
        }
      }
    },
    {
      "externalId": "step3-endocrine-polydipsia-001",
      "expectedHashes": {
        "ranaze_step3_uat": "d70f3a74b03b78071f4ab75a383d1fa44753ff6507042a202a14bdfc6ffa47f6",
        "ranaze_step3_prd": "d70f3a74b03b78071f4ab75a383d1fa44753ff6507042a202a14bdfc6ffa47f6"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
            },
            {
              "id": "B",
              "text": "Option C: Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
            },
            {
              "id": "C",
              "text": "Option D: Hyperglycemia-induced dilutional hyponatremia is inappropriate because a serum glucose of 108 mg/dL is insufficient to explain the hyponatremia through osmotic water shifts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
            },
            {
              "id": "B",
              "text": "Option B: Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
            },
            {
              "id": "C",
              "text": "Option D: Hyperglycemia-induced dilutional hyponatremia is inappropriate because a serum glucose of 108 mg/dL is insufficient to explain the hyponatremia through osmotic water shifts."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hyperglycemia-induced dilutional hyponatremia is inappropriate because a serum glucose of 108 mg/dL is insufficient to explain the hyponatremia through osmotic water shifts."
            },
            {
              "id": "B",
              "text": "Option B: Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
            },
            {
              "id": "C",
              "text": "Option C: Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hyperglycemia-induced dilutional hyponatremia is inappropriate because a serum glucose of 108 mg/dL is insufficient to explain the hyponatremia through osmotic water shifts."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Secondary adrenal insufficiency can cause euvolemic hyponatremia but typically produces inappropriately concentrated urine due to persistent antidiuretic hormone activity."
            },
            {
              "id": "B",
              "text": "Option B: Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
            },
            {
              "id": "C",
              "text": "Option C: Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Secondary adrenal insufficiency can cause euvolemic hyponatremia but typically produces inappropriately concentrated urine due to persistent antidiuretic hormone activity."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Severe primary hypothyroidism is inappropriate because clinically important hyponatremia from hypothyroidism is unusual outside severe disease such as myxedema and is mediated by impaired water excretion. This well-appearing patient instead has appropriately suppressed antidiuretic activity, shown by urine osmolality of 72 mOsm/kg."
            },
            {
              "id": "B",
              "text": "Option B: Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
            },
            {
              "id": "C",
              "text": "Option C: Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Severe primary hypothyroidism is inappropriate because clinically important hyponatremia from hypothyroidism is unusual outside severe disease such as myxedema and is mediated by impaired water excretion. This well-appearing patient instead has appropriately suppressed antidiuretic activity, shown by urine osmolality of 72 mOsm/kg."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduced effective arterial volume from congestive heart failure is inappropriate because heart failure causes hypervolemic hyponatremia through low effective arterial volume and persistent antidiuretic hormone release, leading to nonmaximally dilute urine. This patient has no edema and has urine osmolality of only 72 mOsm/kg."
            },
            {
              "id": "B",
              "text": "Option B: Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
            },
            {
              "id": "C",
              "text": "Option C: Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduced effective arterial volume from congestive heart failure is inappropriate because heart failure causes hypervolemic hyponatremia through low effective arterial volume and persistent antidiuretic hormone release, leading to nonmaximally dilute urine. This patient has no edema and has urine osmolality of only 72 mOsm/kg."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pseudohyponatremia from marked hyperlipidemia or hyperproteinemia is inappropriate because pseudohyponatremia from extreme lipid or protein elevation is an isotonic laboratory artifact. This patient has genuinely hypotonic plasma, with a measured serum osmolality of 266 mOsm/kg."
            },
            {
              "id": "B",
              "text": "Option B: Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
            },
            {
              "id": "C",
              "text": "Option C: Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pseudohyponatremia from marked hyperlipidemia or hyperproteinemia is inappropriate because pseudohyponatremia from extreme lipid or protein elevation is an isotonic laboratory artifact. This patient has genuinely hypotonic plasma, with a measured serum osmolality of 266 mOsm/kg."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Deficient antidiuretic hormone secretion due to central diabetes insipidus is inappropriate because central diabetes insipidus causes hypotonic polyuria and compensatory polydipsia, but without adequate water replacement it raises serum sodium and osmolality rather than causing hypotonic hyponatremia. Here, hyponatremia reflects water intake exceeding excretory capacity."
            },
            {
              "id": "B",
              "text": "Option B: Syndrome of inappropriate antidiuretic hormone secretion is inappropriate because sIADH causes euvolemic hyponatremia with inappropriately concentrated urine, typically with urine osmolality above 100 mOsm/kg."
            },
            {
              "id": "C",
              "text": "Option C: Volume depletion due to gastrointestinal losses is inappropriate because hypovolemia stimulates antidiuretic hormone release, resulting in concentrated urine and clinical evidence of volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Deficient antidiuretic hormone secretion due to central diabetes insipidus is inappropriate because central diabetes insipidus causes hypotonic polyuria and compensatory polydipsia, but without adequate water replacement it raises serum sodium and osmolality rather than causing hypotonic hyponatremia. Here, hyponatremia reflects water intake exceeding excretory capacity."
        }
      }
    },
    {
      "externalId": "step3-endocrinology-female-athlete-triad-dexa-274",
      "expectedHashes": {
        "ranaze_step3_uat": "9952c5753fef28be76328fe3610302465fb3ec524bc3a3858a7e88fef022adce",
        "ranaze_step3_prd": "9952c5753fef28be76328fe3610302465fb3ec524bc3a3858a7e88fef022adce"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the brain with contrast is inappropriate because brain MRI is indicated when central nervous system pathology or pituitary disease is suspected. The clinical picture is most consistent with functional hypothalamic amenorrhea due to low energy availability."
            },
            {
              "id": "B",
              "text": "Option C: Exercise treadmill stress test is inappropriate because exercise stress testing is unnecessary because her symptoms do not occur with exertion and she is a highly trained athlete without evidence of exercise-induced ischemia or arrhythmia."
            },
            {
              "id": "C",
              "text": "Option D: Transvaginal pelvic ultrasonography is inappropriate because pelvic ultrasonography may be useful for structural gynecologic disease but does not evaluate the major long-term complication of prolonged hypothalamic amenorrhea."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the brain with contrast is inappropriate because brain MRI is indicated when central nervous system pathology or pituitary disease is suspected. The clinical picture is most consistent with functional hypothalamic amenorrhea due to low energy availability."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exercise treadmill stress test is inappropriate because exercise stress testing is unnecessary because her symptoms do not occur with exertion and she is a highly trained athlete without evidence of exercise-induced ischemia or arrhythmia."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain with contrast is inappropriate because brain MRI is indicated when central nervous system pathology or pituitary disease is suspected. The clinical picture is most consistent with functional hypothalamic amenorrhea due to low energy availability."
            },
            {
              "id": "C",
              "text": "Option D: Transvaginal pelvic ultrasonography is inappropriate because pelvic ultrasonography may be useful for structural gynecologic disease but does not evaluate the major long-term complication of prolonged hypothalamic amenorrhea."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exercise treadmill stress test is inappropriate because exercise stress testing is unnecessary because her symptoms do not occur with exertion and she is a highly trained athlete without evidence of exercise-induced ischemia or arrhythmia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transvaginal pelvic ultrasonography is inappropriate because pelvic ultrasonography may be useful for structural gynecologic disease but does not evaluate the major long-term complication of prolonged hypothalamic amenorrhea."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain with contrast is inappropriate because brain MRI is indicated when central nervous system pathology or pituitary disease is suspected. The clinical picture is most consistent with functional hypothalamic amenorrhea due to low energy availability."
            },
            {
              "id": "C",
              "text": "Option C: Exercise treadmill stress test is inappropriate because exercise stress testing is unnecessary because her symptoms do not occur with exertion and she is a highly trained athlete without evidence of exercise-induced ischemia or arrhythmia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transvaginal pelvic ultrasonography is inappropriate because pelvic ultrasonography may be useful for structural gynecologic disease but does not evaluate the major long-term complication of prolonged hypothalamic amenorrhea."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Head-up tilt-table testing is inappropriate because tilt-table testing is reserved for patients with suspected neurally mediated syncope when the diagnosis remains uncertain after initial evaluation and would not address her underlying endocrine and skeletal risk."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain with contrast is inappropriate because brain MRI is indicated when central nervous system pathology or pituitary disease is suspected. The clinical picture is most consistent with functional hypothalamic amenorrhea due to low energy availability."
            },
            {
              "id": "C",
              "text": "Option C: Exercise treadmill stress test is inappropriate because exercise stress testing is unnecessary because her symptoms do not occur with exertion and she is a highly trained athlete without evidence of exercise-induced ischemia or arrhythmia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Head-up tilt-table testing is inappropriate because tilt-table testing is reserved for patients with suspected neurally mediated syncope when the diagnosis remains uncertain after initial evaluation and would not address her underlying endocrine and skeletal risk."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transthoracic echocardiography is inappropriate because echocardiography is used when structural heart disease is suspected. This young athlete has no exertional symptoms or abnormal cardiac examination findings; the conspicuous unresolved risk is prolonged hypoestrogenism and low bone mineral density."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain with contrast is inappropriate because brain MRI is indicated when central nervous system pathology or pituitary disease is suspected. The clinical picture is most consistent with functional hypothalamic amenorrhea due to low energy availability."
            },
            {
              "id": "C",
              "text": "Option C: Exercise treadmill stress test is inappropriate because exercise stress testing is unnecessary because her symptoms do not occur with exertion and she is a highly trained athlete without evidence of exercise-induced ischemia or arrhythmia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transthoracic echocardiography is inappropriate because echocardiography is used when structural heart disease is suspected. This young athlete has no exertional symptoms or abnormal cardiac examination findings; the conspicuous unresolved risk is prolonged hypoestrogenism and low bone mineral density."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plain radiography of the lumbar spine is inappropriate because plain radiographs can demonstrate an established fracture but are not the standard test for quantifying early generalized bone loss. Her prolonged amenorrhea and low BMI call for DXA even in the absence of fracture symptoms."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain with contrast is inappropriate because brain MRI is indicated when central nervous system pathology or pituitary disease is suspected. The clinical picture is most consistent with functional hypothalamic amenorrhea due to low energy availability."
            },
            {
              "id": "C",
              "text": "Option C: Exercise treadmill stress test is inappropriate because exercise stress testing is unnecessary because her symptoms do not occur with exertion and she is a highly trained athlete without evidence of exercise-induced ischemia or arrhythmia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plain radiography of the lumbar spine is inappropriate because plain radiographs can demonstrate an established fracture but are not the standard test for quantifying early generalized bone loss. Her prolonged amenorrhea and low BMI call for DXA even in the absence of fracture symptoms."
        }
      }
    },
    {
      "externalId": "step3-endocrinology-hypoglycemia-unawareness-1938",
      "expectedHashes": {
        "ranaze_step3_uat": "ee328fda73a0815eea184532d3e29fcef75935f43a68da10399cff873f2346a8",
        "ranaze_step3_prd": "ee328fda73a0815eea184532d3e29fcef75935f43a68da10399cff873f2346a8"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
            },
            {
              "id": "B",
              "text": "Option C: Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
            },
            {
              "id": "C",
              "text": "Option D: Suppression of adrenergic symptoms by insulin itself is inappropriate because insulin lowers glucose but does not directly suppress the autonomic warning symptoms of hypoglycemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
            },
            {
              "id": "B",
              "text": "Option B: Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
            },
            {
              "id": "C",
              "text": "Option D: Suppression of adrenergic symptoms by insulin itself is inappropriate because insulin lowers glucose but does not directly suppress the autonomic warning symptoms of hypoglycemia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Suppression of adrenergic symptoms by insulin itself is inappropriate because insulin lowers glucose but does not directly suppress the autonomic warning symptoms of hypoglycemia."
            },
            {
              "id": "B",
              "text": "Option B: Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
            },
            {
              "id": "C",
              "text": "Option C: Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Suppression of adrenergic symptoms by insulin itself is inappropriate because insulin lowers glucose but does not directly suppress the autonomic warning symptoms of hypoglycemia."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lack of knowledge regarding the manifestations of hypoglycemia is inappropriate because the patient lacks physiologic symptoms rather than merely failing to understand them; his wife observes neuroglycopenic changes such as confusion and irritability."
            },
            {
              "id": "B",
              "text": "Option B: Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
            },
            {
              "id": "C",
              "text": "Option C: Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lack of knowledge regarding the manifestations of hypoglycemia is inappropriate because the patient lacks physiologic symptoms rather than merely failing to understand them; his wife observes neuroglycopenic changes such as confusion and irritability."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reduced renal clearance of exogenous insulin as kidney function declines is inappropriate because declining kidney function reduces insulin clearance and can increase the frequency and duration of hypoglycemia. It does not specifically explain why documented glucose values of 42\u201358 mg/dL produce no tremor, sweating, palpitations, hunger, or anxiety."
            },
            {
              "id": "B",
              "text": "Option B: Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
            },
            {
              "id": "C",
              "text": "Option C: Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reduced renal clearance of exogenous insulin as kidney function declines is inappropriate because declining kidney function reduces insulin clearance and can increase the frequency and duration of hypoglycemia. It does not specifically explain why documented glucose values of 42\u201358 mg/dL produce no tremor, sweating, palpitations, hunger, or anxiety."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An excessive lunchtime prandial insulin dose is inappropriate because excess prandial insulin could explain recurrent late-afternoon hypoglycemia, but the question asks why the patient lacks autonomic warning symptoms. Insulin excess does not itself selectively suppress the sympathoadrenal response."
            },
            {
              "id": "B",
              "text": "Option B: Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
            },
            {
              "id": "C",
              "text": "Option C: Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An excessive lunchtime prandial insulin dose is inappropriate because excess prandial insulin could explain recurrent late-afternoon hypoglycemia, but the question asks why the patient lacks autonomic warning symptoms. Insulin excess does not itself selectively suppress the sympathoadrenal response."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Loss of the pancreatic glucagon response in long-standing type 1 diabetes is inappropriate because loss of glucagon counterregulation in long-standing type 1 diabetes increases susceptibility to hypoglycemia. However, typical warning symptoms are generated principally by sympathoadrenal activation; their disappearance after recurrent hypoglycemia reflects a blunted autonomic response, not isolated glucagon deficiency."
            },
            {
              "id": "B",
              "text": "Option B: Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
            },
            {
              "id": "C",
              "text": "Option C: Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Loss of the pancreatic glucagon response in long-standing type 1 diabetes is inappropriate because loss of glucagon counterregulation in long-standing type 1 diabetes increases susceptibility to hypoglycemia. However, typical warning symptoms are generated principally by sympathoadrenal activation; their disappearance after recurrent hypoglycemia reflects a blunted autonomic response, not isolated glucagon deficiency."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Peripheral sensory neuropathy preventing perception of autonomic symptoms is inappropriate because peripheral sensory neuropathy explains reduced vibration and pinprick sensation in the feet, not failure to experience centrally generated adrenergic manifestations such as sweating, palpitations, hunger, and anxiety. The orthostatic findings and recurrent hypoglycemia instead support autonomic counterregulatory failure."
            },
            {
              "id": "B",
              "text": "Option B: Falsely low glucose readings caused by chronic kidney disease is inappropriate because chronic kidney disease increases hypoglycemia risk by reducing insulin clearance, but it does not generally cause consistently false glucose readings."
            },
            {
              "id": "C",
              "text": "Option C: Inability to recognize the glucose display because of diabetic retinopathy is inappropriate because visual impairment could interfere with reading a device, but this patient is alerted by a continuous glucose monitor and has objectively low recorded values."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Peripheral sensory neuropathy preventing perception of autonomic symptoms is inappropriate because peripheral sensory neuropathy explains reduced vibration and pinprick sensation in the feet, not failure to experience centrally generated adrenergic manifestations such as sweating, palpitations, hunger, and anxiety. The orthostatic findings and recurrent hypoglycemia instead support autonomic counterregulatory failure."
        }
      }
    },
    {
      "externalId": "step3-endocrinology-hypothyroidism-pregnancy-701",
      "expectedHashes": {
        "ranaze_step3_uat": "9a70fb8f186cd5cfcfb57580e0e293d9aa0c61a10161ad89f272946d723d369f",
        "ranaze_step3_prd": "9a70fb8f186cd5cfcfb57580e0e293d9aa0c61a10161ad89f272946d723d369f"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The levothyroxine dose will likely decrease because fetal thyroid hormone production supplements maternal hormone levels. is inappropriate because the fetus does not provide thyroid hormone to the mother. Maternal thyroid hormone supports the fetus, especially during the first trimester."
            },
            {
              "id": "B",
              "text": "Option C: The levothyroxine dose will likely remain unchanged because maternal free thyroxine concentrations are tightly regulated throughout pregnancy. is inappropriate because most women with established hypothyroidism require a higher levothyroxine dose during pregnancy rather than maintaining the same dose."
            },
            {
              "id": "C",
              "text": "Option D: The levothyroxine dose will likely increase primarily because of increased placental transfer of maternal thyroid hormone to the fetus. is inappropriate because only a small amount of maternal thyroid hormone crosses the placenta. Increased TBG is the primary reason for higher levothyroxine requirements."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The levothyroxine dose will likely decrease because fetal thyroid hormone production supplements maternal hormone levels. is inappropriate because the fetus does not provide thyroid hormone to the mother. Maternal thyroid hormone supports the fetus, especially during the first trimester."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The levothyroxine dose will likely remain unchanged because maternal free thyroxine concentrations are tightly regulated throughout pregnancy. is inappropriate because most women with established hypothyroidism require a higher levothyroxine dose during pregnancy rather than maintaining the same dose."
            },
            {
              "id": "B",
              "text": "Option B: The levothyroxine dose will likely decrease because fetal thyroid hormone production supplements maternal hormone levels. is inappropriate because the fetus does not provide thyroid hormone to the mother. Maternal thyroid hormone supports the fetus, especially during the first trimester."
            },
            {
              "id": "C",
              "text": "Option D: The levothyroxine dose will likely increase primarily because of increased placental transfer of maternal thyroid hormone to the fetus. is inappropriate because only a small amount of maternal thyroid hormone crosses the placenta. Increased TBG is the primary reason for higher levothyroxine requirements."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The levothyroxine dose will likely remain unchanged because maternal free thyroxine concentrations are tightly regulated throughout pregnancy. is inappropriate because most women with established hypothyroidism require a higher levothyroxine dose during pregnancy rather than maintaining the same dose."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The levothyroxine dose will likely increase primarily because of increased placental transfer of maternal thyroid hormone to the fetus. is inappropriate because only a small amount of maternal thyroid hormone crosses the placenta. Increased TBG is the primary reason for higher levothyroxine requirements."
            },
            {
              "id": "B",
              "text": "Option B: The levothyroxine dose will likely decrease because fetal thyroid hormone production supplements maternal hormone levels. is inappropriate because the fetus does not provide thyroid hormone to the mother. Maternal thyroid hormone supports the fetus, especially during the first trimester."
            },
            {
              "id": "C",
              "text": "Option C: The levothyroxine dose will likely remain unchanged because maternal free thyroxine concentrations are tightly regulated throughout pregnancy. is inappropriate because most women with established hypothyroidism require a higher levothyroxine dose during pregnancy rather than maintaining the same dose."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The levothyroxine dose will likely increase primarily because of increased placental transfer of maternal thyroid hormone to the fetus. is inappropriate because only a small amount of maternal thyroid hormone crosses the placenta. Increased TBG is the primary reason for higher levothyroxine requirements."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The levothyroxine dose will likely decrease because pregnancy suppresses thyroid-stimulating hormone secretion. is inappropriate because pregnancy does not reduce levothyroxine requirements through TSH suppression. Although hCG may transiently lower TSH early in pregnancy, the dominant effect is increased TBG, resulting in a higher hormone requirement."
            },
            {
              "id": "B",
              "text": "Option B: The levothyroxine dose will likely decrease because fetal thyroid hormone production supplements maternal hormone levels. is inappropriate because the fetus does not provide thyroid hormone to the mother. Maternal thyroid hormone supports the fetus, especially during the first trimester."
            },
            {
              "id": "C",
              "text": "Option C: The levothyroxine dose will likely remain unchanged because maternal free thyroxine concentrations are tightly regulated throughout pregnancy. is inappropriate because most women with established hypothyroidism require a higher levothyroxine dose during pregnancy rather than maintaining the same dose."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The levothyroxine dose will likely decrease because pregnancy suppresses thyroid-stimulating hormone secretion. is inappropriate because pregnancy does not reduce levothyroxine requirements through TSH suppression. Although hCG may transiently lower TSH early in pregnancy, the dominant effect is increased TBG, resulting in a higher hormone requirement."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continue the prepregnancy dose until TSH becomes elevated, and increase it only then is inappropriate because women already taking levothyroxine should generally increase the dose by approximately 20%-30% as soon as pregnancy is confirmed and obtain prompt thyroid testing. Waiting for TSH to rise can expose the early pregnancy to avoidable maternal hypothyroidism."
            },
            {
              "id": "B",
              "text": "Option B: The levothyroxine dose will likely decrease because fetal thyroid hormone production supplements maternal hormone levels. is inappropriate because the fetus does not provide thyroid hormone to the mother. Maternal thyroid hormone supports the fetus, especially during the first trimester."
            },
            {
              "id": "C",
              "text": "Option C: The levothyroxine dose will likely remain unchanged because maternal free thyroxine concentrations are tightly regulated throughout pregnancy. is inappropriate because most women with established hypothyroidism require a higher levothyroxine dose during pregnancy rather than maintaining the same dose."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continue the prepregnancy dose until TSH becomes elevated, and increase it only then is inappropriate because women already taking levothyroxine should generally increase the dose by approximately 20%-30% as soon as pregnancy is confirmed and obtain prompt thyroid testing. Waiting for TSH to rise can expose the early pregnancy to avoidable maternal hypothyroidism."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer any dose increase until the second trimester, when fetal thyroid hormone needs increase is inappropriate because levothyroxine requirements can rise as early as 4-6 weeks of gestation. The dose increase should not be deferred until the second trimester, particularly because fetal development initially depends on maternal T4."
            },
            {
              "id": "B",
              "text": "Option B: The levothyroxine dose will likely decrease because fetal thyroid hormone production supplements maternal hormone levels. is inappropriate because the fetus does not provide thyroid hormone to the mother. Maternal thyroid hormone supports the fetus, especially during the first trimester."
            },
            {
              "id": "C",
              "text": "Option C: The levothyroxine dose will likely remain unchanged because maternal free thyroxine concentrations are tightly regulated throughout pregnancy. is inappropriate because most women with established hypothyroidism require a higher levothyroxine dose during pregnancy rather than maintaining the same dose."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer any dose increase until the second trimester, when fetal thyroid hormone needs increase is inappropriate because levothyroxine requirements can rise as early as 4-6 weeks of gestation. The dose increase should not be deferred until the second trimester, particularly because fetal development initially depends on maternal T4."
        }
      }
    },
    {
      "externalId": "step3-endocrinology-primary-hyperaldosteronism-screening-2089",
      "expectedHashes": {
        "ranaze_step3_uat": "eaf0d1a97b7ee049ae262e702f54a369c75de2850980d6e6448a2ad6754a2431",
        "ranaze_step3_prd": "eaf0d1a97b7ee049ae262e702f54a369c75de2850980d6e6448a2ad6754a2431"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "B",
              "text": "Option C: Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            },
            {
              "id": "C",
              "text": "Option D: Order a 24-hour urine protein measurement is inappropriate because proteinuria does not explain the electrolyte abnormalities, and renal function is preserved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            },
            {
              "id": "B",
              "text": "Option B: Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "C",
              "text": "Option D: Order a 24-hour urine protein measurement is inappropriate because proteinuria does not explain the electrolyte abnormalities, and renal function is preserved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order a 24-hour urine protein measurement is inappropriate because proteinuria does not explain the electrolyte abnormalities, and renal function is preserved."
            },
            {
              "id": "B",
              "text": "Option B: Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "C",
              "text": "Option C: Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order a 24-hour urine protein measurement is inappropriate because proteinuria does not explain the electrolyte abnormalities, and renal function is preserved."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform an ACTH stimulation test is inappropriate because aCTH stimulation testing is used to evaluate adrenal insufficiency, which typically causes hypotension, hyperkalemia, and hyponatremia rather than hypertension with hypokalemia."
            },
            {
              "id": "B",
              "text": "Option B: Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "C",
              "text": "Option C: Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform an ACTH stimulation test is inappropriate because aCTH stimulation testing is used to evaluate adrenal insufficiency, which typically causes hypotension, hyperkalemia, and hyponatremia rather than hypertension with hypokalemia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure plasma free metanephrines is inappropriate because metanephrine testing evaluates pheochromocytoma or paraganglioma. This patient\u0027s sustained hypertension with spontaneous hypokalemia and metabolic alkalosis is a mineralocorticoid-excess pattern, without a catecholamine-excess syndrome in the stem."
            },
            {
              "id": "B",
              "text": "Option B: Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "C",
              "text": "Option C: Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure plasma free metanephrines is inappropriate because metanephrine testing evaluates pheochromocytoma or paraganglioma. This patient\u0027s sustained hypertension with spontaneous hypokalemia and metabolic alkalosis is a mineralocorticoid-excess pattern, without a catecholamine-excess syndrome in the stem."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a 1-mg overnight dexamethasone suppression test is inappropriate because an overnight dexamethasone suppression test screens for hypercortisolism. The stem lacks progressive discriminatory features of Cushing syndrome, whereas hypertension, hypokalemia, and metabolic alkalosis directly indicate primary-aldosteronism screening."
            },
            {
              "id": "B",
              "text": "Option B: Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "C",
              "text": "Option C: Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a 1-mg overnight dexamethasone suppression test is inappropriate because an overnight dexamethasone suppression test screens for hypercortisolism. The stem lacks progressive discriminatory features of Cushing syndrome, whereas hypertension, hypokalemia, and metabolic alkalosis directly indicate primary-aldosteronism screening."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain duplex ultrasonography of the renal arteries is inappropriate because renal-artery imaging can evaluate renovascular hypertension, but it is not the best initial test for this electrolyte phenotype. Spontaneous hypokalemic metabolic alkalosis should first prompt aldosterone and renin measurement."
            },
            {
              "id": "B",
              "text": "Option B: Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "C",
              "text": "Option C: Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain duplex ultrasonography of the renal arteries is inappropriate because renal-artery imaging can evaluate renovascular hypertension, but it is not the best initial test for this electrolyte phenotype. Spontaneous hypokalemic metabolic alkalosis should first prompt aldosterone and renin measurement."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure a spot urine potassium-to-creatinine ratio is inappropriate because a urine potassium-to-creatinine ratio could demonstrate renal potassium loss but would not identify its cause. Hypertension plus hypokalemic metabolic alkalosis already makes aldosterone-renin screening the more direct next evaluation."
            },
            {
              "id": "B",
              "text": "Option B: Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "C",
              "text": "Option C: Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure a spot urine potassium-to-creatinine ratio is inappropriate because a urine potassium-to-creatinine ratio could demonstrate renal potassium loss but would not identify its cause. Hypertension plus hypokalemic metabolic alkalosis already makes aldosterone-renin screening the more direct next evaluation."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure serum thyroid-stimulating hormone and free thyroxine is inappropriate because thyroid testing may be considered for otherwise unexplained weakness, but thyroid disease does not account for this characteristic combination of hypertension, hypokalemia, and metabolic alkalosis."
            },
            {
              "id": "B",
              "text": "Option B: Perform a captopril suppression test is inappropriate because the captopril suppression test is a confirmatory test considered after aldosterone and renin screening rather than the initial test."
            },
            {
              "id": "C",
              "text": "Option C: Obtain electromyography and nerve conduction studies is inappropriate because electrodiagnostic studies evaluate neuromuscular disorders but do not explain the combination of hypertension, hypokalemia, and metabolic alkalosis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure serum thyroid-stimulating hormone and free thyroxine is inappropriate because thyroid testing may be considered for otherwise unexplained weakness, but thyroid disease does not account for this characteristic combination of hypertension, hypokalemia, and metabolic alkalosis."
        }
      }
    },
    {
      "externalId": "step3-ethics-adolescent-prognosis-671",
      "expectedHashes": {
        "ranaze_step3_uat": "6be098653a6fcb35a078cd48917876d2e9bf1ef6fcb8e8a7ca53a831bdb15050",
        "ranaze_step3_prd": "6be098653a6fcb35a078cd48917876d2e9bf1ef6fcb8e8a7ca53a831bdb15050"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Because you are a minor, I need your father\u0027s permission before discussing your prognosis with you. is inappropriate because parents generally make medical decisions for minors, but adolescents should receive developmentally appropriate information and participate in discussions about their illness, especially when they ask directly."
            },
            {
              "id": "B",
              "text": "Option C: Your condition is terminal, and we should begin hospice care immediately. is inappropriate because hospice may eventually be appropriate, but abruptly declaring the illness terminal and prescribing a plan without first assessing the patient\u0027s understanding and preferences is poor communication."
            },
            {
              "id": "C",
              "text": "Option D: I don\u0027t think discussing that right now would be helpful. is inappropriate because avoiding the question disregards the adolescent\u0027s clearly expressed desire for information and undermines trust."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Because you are a minor, I need your father\u0027s permission before discussing your prognosis with you. is inappropriate because parents generally make medical decisions for minors, but adolescents should receive developmentally appropriate information and participate in discussions about their illness, especially when they ask directly."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Your condition is terminal, and we should begin hospice care immediately. is inappropriate because hospice may eventually be appropriate, but abruptly declaring the illness terminal and prescribing a plan without first assessing the patient\u0027s understanding and preferences is poor communication."
            },
            {
              "id": "B",
              "text": "Option A: Because you are a minor, I need your father\u0027s permission before discussing your prognosis with you. is inappropriate because parents generally make medical decisions for minors, but adolescents should receive developmentally appropriate information and participate in discussions about their illness, especially when they ask directly."
            },
            {
              "id": "C",
              "text": "Option D: I don\u0027t think discussing that right now would be helpful. is inappropriate because avoiding the question disregards the adolescent\u0027s clearly expressed desire for information and undermines trust."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Your condition is terminal, and we should begin hospice care immediately. is inappropriate because hospice may eventually be appropriate, but abruptly declaring the illness terminal and prescribing a plan without first assessing the patient\u0027s understanding and preferences is poor communication."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "I don\u0027t think discussing that right now would be helpful. is inappropriate because avoiding the question disregards the adolescent\u0027s clearly expressed desire for information and undermines trust."
            },
            {
              "id": "B",
              "text": "Option A: Because you are a minor, I need your father\u0027s permission before discussing your prognosis with you. is inappropriate because parents generally make medical decisions for minors, but adolescents should receive developmentally appropriate information and participate in discussions about their illness, especially when they ask directly."
            },
            {
              "id": "C",
              "text": "Option C: Your condition is terminal, and we should begin hospice care immediately. is inappropriate because hospice may eventually be appropriate, but abruptly declaring the illness terminal and prescribing a plan without first assessing the patient\u0027s understanding and preferences is poor communication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "I don\u0027t think discussing that right now would be helpful. is inappropriate because avoiding the question disregards the adolescent\u0027s clearly expressed desire for information and undermines trust."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Have you been taking all of your medications exactly as prescribed at home? is inappropriate because medication adherence may be clinically relevant, but this response redirects the conversation and does not address the patient\u0027s request."
            },
            {
              "id": "B",
              "text": "Option A: Because you are a minor, I need your father\u0027s permission before discussing your prognosis with you. is inappropriate because parents generally make medical decisions for minors, but adolescents should receive developmentally appropriate information and participate in discussions about their illness, especially when they ask directly."
            },
            {
              "id": "C",
              "text": "Option C: Your condition is terminal, and we should begin hospice care immediately. is inappropriate because hospice may eventually be appropriate, but abruptly declaring the illness terminal and prescribing a plan without first assessing the patient\u0027s understanding and preferences is poor communication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Have you been taking all of your medications exactly as prescribed at home? is inappropriate because medication adherence may be clinically relevant, but this response redirects the conversation and does not address the patient\u0027s request."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Try to stay positive; you may still become eligible for transplantation. is inappropriate because this is unsupported reassurance: the transplant center has already found her ineligible because of severe pulmonary hypertension."
            },
            {
              "id": "B",
              "text": "Option A: Because you are a minor, I need your father\u0027s permission before discussing your prognosis with you. is inappropriate because parents generally make medical decisions for minors, but adolescents should receive developmentally appropriate information and participate in discussions about their illness, especially when they ask directly."
            },
            {
              "id": "C",
              "text": "Option C: Your condition is terminal, and we should begin hospice care immediately. is inappropriate because hospice may eventually be appropriate, but abruptly declaring the illness terminal and prescribing a plan without first assessing the patient\u0027s understanding and preferences is poor communication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Try to stay positive; you may still become eligible for transplantation. is inappropriate because this is unsupported reassurance: the transplant center has already found her ineligible because of severe pulmonary hypertension."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "I will ask the palliative care team to discuss this with you later. is inappropriate because palliative care involvement may be helpful, but deferring the patient\u0027s direct question without first acknowledging and exploring it abandons the immediate communication responsibility."
            },
            {
              "id": "B",
              "text": "Option A: Because you are a minor, I need your father\u0027s permission before discussing your prognosis with you. is inappropriate because parents generally make medical decisions for minors, but adolescents should receive developmentally appropriate information and participate in discussions about their illness, especially when they ask directly."
            },
            {
              "id": "C",
              "text": "Option C: Your condition is terminal, and we should begin hospice care immediately. is inappropriate because hospice may eventually be appropriate, but abruptly declaring the illness terminal and prescribing a plan without first assessing the patient\u0027s understanding and preferences is poor communication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "I will ask the palliative care team to discuss this with you later. is inappropriate because palliative care involvement may be helpful, but deferring the patient\u0027s direct question without first acknowledging and exploring it abandons the immediate communication responsibility."
        }
      }
    },
    {
      "externalId": "step3-ethics-decision-making-capacity-521",
      "expectedHashes": {
        "ranaze_step3_uat": "ca6a461e451b0b0cd195c209783c139c590dd3c2e8884d2985e2162856477b70",
        "ranaze_step3_prd": "ca6a461e451b0b0cd195c209783c139c590dd3c2e8884d2985e2162856477b70"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Honor the patient\u0027s refusal and provide comfort-focused treatment only is inappropriate because a refusal made without decision-making capacity is not controlling when an authorized surrogate is available to guide treatment."
            },
            {
              "id": "B",
              "text": "Option C: Request an emergency psychiatry consultation to determine decision-making capacity is inappropriate because the treating physician can assess decision-making capacity; psychiatry consultation is not routinely required and should not delay emergency care."
            },
            {
              "id": "C",
              "text": "Option D: Seek approval from the hospital ethics committee before proceeding is inappropriate because ethics consultation is useful for unresolved disputes or questionable surrogate decisions but is not required before urgent treatment when the authorized surrogate is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Honor the patient\u0027s refusal and provide comfort-focused treatment only is inappropriate because a refusal made without decision-making capacity is not controlling when an authorized surrogate is available to guide treatment."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request an emergency psychiatry consultation to determine decision-making capacity is inappropriate because the treating physician can assess decision-making capacity; psychiatry consultation is not routinely required and should not delay emergency care."
            },
            {
              "id": "B",
              "text": "Option B: Honor the patient\u0027s refusal and provide comfort-focused treatment only is inappropriate because a refusal made without decision-making capacity is not controlling when an authorized surrogate is available to guide treatment."
            },
            {
              "id": "C",
              "text": "Option D: Seek approval from the hospital ethics committee before proceeding is inappropriate because ethics consultation is useful for unresolved disputes or questionable surrogate decisions but is not required before urgent treatment when the authorized surrogate is available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request an emergency psychiatry consultation to determine decision-making capacity is inappropriate because the treating physician can assess decision-making capacity; psychiatry consultation is not routinely required and should not delay emergency care."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Seek approval from the hospital ethics committee before proceeding is inappropriate because ethics consultation is useful for unresolved disputes or questionable surrogate decisions but is not required before urgent treatment when the authorized surrogate is available."
            },
            {
              "id": "B",
              "text": "Option B: Honor the patient\u0027s refusal and provide comfort-focused treatment only is inappropriate because a refusal made without decision-making capacity is not controlling when an authorized surrogate is available to guide treatment."
            },
            {
              "id": "C",
              "text": "Option C: Request an emergency psychiatry consultation to determine decision-making capacity is inappropriate because the treating physician can assess decision-making capacity; psychiatry consultation is not routinely required and should not delay emergency care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Seek approval from the hospital ethics committee before proceeding is inappropriate because ethics consultation is useful for unresolved disputes or questionable surrogate decisions but is not required before urgent treatment when the authorized surrogate is available."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay surgery until the patient becomes more oriented and can provide informed consent is inappropriate because waiting for capacity to return is inappropriate because the patient has a time-sensitive surgical emergency."
            },
            {
              "id": "B",
              "text": "Option B: Honor the patient\u0027s refusal and provide comfort-focused treatment only is inappropriate because a refusal made without decision-making capacity is not controlling when an authorized surrogate is available to guide treatment."
            },
            {
              "id": "C",
              "text": "Option C: Request an emergency psychiatry consultation to determine decision-making capacity is inappropriate because the treating physician can assess decision-making capacity; psychiatry consultation is not routinely required and should not delay emergency care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay surgery until the patient becomes more oriented and can provide informed consent is inappropriate because waiting for capacity to return is inappropriate because the patient has a time-sensitive surgical emergency."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed under implied emergency consent without involving the patient\u0027s daughter is inappropriate because emergency treatment may proceed without consent when an incapacitated patient has no available authorized surrogate. Here, the patient\u0027s designated health care agent is present, so she should be involved immediately without delaying the operation."
            },
            {
              "id": "B",
              "text": "Option B: Honor the patient\u0027s refusal and provide comfort-focused treatment only is inappropriate because a refusal made without decision-making capacity is not controlling when an authorized surrogate is available to guide treatment."
            },
            {
              "id": "C",
              "text": "Option C: Request an emergency psychiatry consultation to determine decision-making capacity is inappropriate because the treating physician can assess decision-making capacity; psychiatry consultation is not routinely required and should not delay emergency care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed under implied emergency consent without involving the patient\u0027s daughter is inappropriate because emergency treatment may proceed without consent when an incapacitated patient has no available authorized surrogate. Here, the patient\u0027s designated health care agent is present, so she should be involved immediately without delaying the operation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a Mini-Mental State Examination to determine whether the refusal is valid is inappropriate because a global cognitive screening score does not by itself determine decision-making capacity. Capacity is decision-specific and is assessed through the patient\u0027s ability to understand, appreciate, reason about, and communicate a choice regarding the proposed treatment; the stem already establishes critical deficits."
            },
            {
              "id": "B",
              "text": "Option B: Honor the patient\u0027s refusal and provide comfort-focused treatment only is inappropriate because a refusal made without decision-making capacity is not controlling when an authorized surrogate is available to guide treatment."
            },
            {
              "id": "C",
              "text": "Option C: Request an emergency psychiatry consultation to determine decision-making capacity is inappropriate because the treating physician can assess decision-making capacity; psychiatry consultation is not routinely required and should not delay emergency care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a Mini-Mental State Examination to determine whether the refusal is valid is inappropriate because a global cognitive screening score does not by itself determine decision-making capacity. Capacity is decision-specific and is assessed through the patient\u0027s ability to understand, appreciate, reason about, and communicate a choice regarding the proposed treatment; the stem already establishes critical deficits."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Require the daughter to identify a prior explicit treatment preference before she may authorize surgery is inappropriate because when the patient\u0027s relevant preferences and values are unknown, the designated surrogate does not lose authority. She should instead use the best-interest standard, considering the burdens and likely benefits of emergency surgery."
            },
            {
              "id": "B",
              "text": "Option B: Honor the patient\u0027s refusal and provide comfort-focused treatment only is inappropriate because a refusal made without decision-making capacity is not controlling when an authorized surrogate is available to guide treatment."
            },
            {
              "id": "C",
              "text": "Option C: Request an emergency psychiatry consultation to determine decision-making capacity is inappropriate because the treating physician can assess decision-making capacity; psychiatry consultation is not routinely required and should not delay emergency care."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Require the daughter to identify a prior explicit treatment preference before she may authorize surgery is inappropriate because when the patient\u0027s relevant preferences and values are unknown, the designated surrogate does not lose authority. She should instead use the best-interest standard, considering the burdens and likely benefits of emergency surgery."
        }
      }
    },
    {
      "externalId": "step3-ethics-decision-making-capacity-552",
      "expectedHashes": {
        "ranaze_step3_uat": "5636eb487a22d3e7f3dacefe4e6607873417c996b1718b296b231b1c7fad64fd",
        "ranaze_step3_prd": "5636eb487a22d3e7f3dacefe4e6607873417c996b1718b296b231b1c7fad64fd"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "B",
              "text": "Option C: Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option D: Request immediate appointment of a court-appointed guardian before making treatment decisions is inappropriate because court-appointed guardianship is reserved for patients without decision-making capacity when no appropriate surrogate is available or there is irresolvable conflict."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            },
            {
              "id": "B",
              "text": "Option B: Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option D: Request immediate appointment of a court-appointed guardian before making treatment decisions is inappropriate because court-appointed guardianship is reserved for patients without decision-making capacity when no appropriate surrogate is available or there is irresolvable conflict."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request immediate appointment of a court-appointed guardian before making treatment decisions is inappropriate because court-appointed guardianship is reserved for patients without decision-making capacity when no appropriate surrogate is available or there is irresolvable conflict."
            },
            {
              "id": "B",
              "text": "Option B: Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request immediate appointment of a court-appointed guardian before making treatment decisions is inappropriate because court-appointed guardianship is reserved for patients without decision-making capacity when no appropriate surrogate is available or there is irresolvable conflict."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Consult the hospital ethics committee before speaking with the patient is inappropriate because an ethics consultation can be helpful in difficult disputes but should not precede assessment of a capable patient\u0027s own preferences."
            },
            {
              "id": "B",
              "text": "Option B: Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Consult the hospital ethics committee before speaking with the patient is inappropriate because an ethics consultation can be helpful in difficult disputes but should not precede assessment of a capable patient\u0027s own preferences."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed with immediate endotracheal intubation under the emergency exception to informed consent is inappropriate because emergency treatment without consent is reserved for an urgent threat when the patient cannot participate and no surrogate is available. She is awake and answering questions and has not been assessed; her current preferences and capacity must be elicited before overriding autonomy."
            },
            {
              "id": "B",
              "text": "Option B: Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed with immediate endotracheal intubation under the emergency exception to informed consent is inappropriate because emergency treatment without consent is reserved for an urgent threat when the patient cannot participate and no surrogate is available. She is awake and answering questions and has not been assessed; her current preferences and capacity must be elicited before overriding autonomy."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer discussion of treatment preferences until the pneumonia and hypoxemia have resolved is inappropriate because capacity is decision-specific and time-specific. Acute illness can impair it, but pneumonia, fatigue, oxygen therapy, or advanced age does not establish incapacity; delaying may deprive a currently capable patient of control over imminent life-sustaining treatment."
            },
            {
              "id": "B",
              "text": "Option B: Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer discussion of treatment preferences until the pneumonia and hypoxemia have resolved is inappropriate because capacity is decision-specific and time-specific. Acute illness can impair it, but pneumonia, fatigue, oxygen therapy, or advanced age does not establish incapacity; delaying may deprive a currently capable patient of control over imminent life-sustaining treatment."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request a psychiatric consultation to determine decision-making capacity is inappropriate because the treating physician can perform the initial capacity assessment. Psychiatry is useful when mental illness, suicidality, or an unusually complex assessment creates uncertainty, none of which has yet been demonstrated."
            },
            {
              "id": "B",
              "text": "Option B: Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request a psychiatric consultation to determine decision-making capacity is inappropriate because the treating physician can perform the initial capacity assessment. Psychiatry is useful when mental illness, suicidality, or an unusually complex assessment creates uncertainty, none of which has yet been demonstrated."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a standardized cognitive screening test and use its score to determine capacity is inappropriate because cognitive screening may supplement an evaluation but cannot independently establish decision-making capacity. Capacity requires assessment of understanding, appreciation, reasoning, and ability to communicate a choice about the specific decision."
            },
            {
              "id": "B",
              "text": "Option B: Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a standardized cognitive screening test and use its score to determine capacity is inappropriate because cognitive screening may supplement an evaluation but cannot independently establish decision-making capacity. Capacity requires assessment of understanding, appreciation, reasoning, and ability to communicate a choice about the specific decision."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Presume that the patient lacks capacity due to her age and hypoxemic illness and apply the best-interest standard is inappropriate because neither advanced age nor hypoxemia automatically eliminates capacity. The best-interest standard applies only after incapacity is established and the patient\u0027s preferences cannot be adequately determined through substituted judgment."
            },
            {
              "id": "B",
              "text": "Option B: Follow the daughter\u0027s request because she is the closest biological relative is inappropriate because biologic relationship alone does not override the patient\u0027s own autonomous decisions when she has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Follow the neighbor\u0027s request because the neighbor knows the patient best is inappropriate because although the neighbor may know the patient\u0027s prior wishes, surrogate input is appropriate only if the patient lacks decision-making capacity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Presume that the patient lacks capacity due to her age and hypoxemic illness and apply the best-interest standard is inappropriate because neither advanced age nor hypoxemia automatically eliminates capacity. The best-interest standard applies only after incapacity is established and the patient\u0027s preferences cannot be adequately determined through substituted judgment."
        }
      }
    },
    {
      "externalId": "step3-ethics-emotion-empathy-adoptive-parents-2198",
      "expectedHashes": {
        "ranaze_step3_uat": "438ff6f8c0e579d896c756ff7f9a3878e78d53ee5a1ed2b788644cf8aaf33431"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fortunately, this condition is very treatable, so there\u0027s no reason to be upset. is inappropriate because premature reassurance minimizes the father\u0027s emotions and may hinder communication, even if the prognosis is favorable."
            },
            {
              "id": "B",
              "text": "Option C: Children adopted internationally often have medical problems like this. is inappropriate because providing general information before addressing the parent\u0027s distress overlooks the emotional cue."
            },
            {
              "id": "C",
              "text": "Option D: Would you like me to refer you to another pediatric specialist for a second opinion? is inappropriate because there is no indication that a second opinion is needed; the immediate priority is responding empathetically to the father\u0027s emotions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fortunately, this condition is very treatable, so there\u0027s no reason to be upset. is inappropriate because premature reassurance minimizes the father\u0027s emotions and may hinder communication, even if the prognosis is favorable."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Children adopted internationally often have medical problems like this. is inappropriate because providing general information before addressing the parent\u0027s distress overlooks the emotional cue."
            },
            {
              "id": "B",
              "text": "Option B: Fortunately, this condition is very treatable, so there\u0027s no reason to be upset. is inappropriate because premature reassurance minimizes the father\u0027s emotions and may hinder communication, even if the prognosis is favorable."
            },
            {
              "id": "C",
              "text": "Option D: Would you like me to refer you to another pediatric specialist for a second opinion? is inappropriate because there is no indication that a second opinion is needed; the immediate priority is responding empathetically to the father\u0027s emotions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Children adopted internationally often have medical problems like this. is inappropriate because providing general information before addressing the parent\u0027s distress overlooks the emotional cue."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Would you like me to refer you to another pediatric specialist for a second opinion? is inappropriate because there is no indication that a second opinion is needed; the immediate priority is responding empathetically to the father\u0027s emotions."
            },
            {
              "id": "B",
              "text": "Option B: Fortunately, this condition is very treatable, so there\u0027s no reason to be upset. is inappropriate because premature reassurance minimizes the father\u0027s emotions and may hinder communication, even if the prognosis is favorable."
            },
            {
              "id": "C",
              "text": "Option C: Children adopted internationally often have medical problems like this. is inappropriate because providing general information before addressing the parent\u0027s distress overlooks the emotional cue."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Would you like me to refer you to another pediatric specialist for a second opinion? is inappropriate because there is no indication that a second opinion is needed; the immediate priority is responding empathetically to the father\u0027s emotions."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Let\u0027s first discuss the treatment plan, and we can address your concerns afterward. is inappropriate because deferring the emotional discussion misses an opportunity to build rapport and address the family\u0027s immediate concerns."
            },
            {
              "id": "B",
              "text": "Option B: Fortunately, this condition is very treatable, so there\u0027s no reason to be upset. is inappropriate because premature reassurance minimizes the father\u0027s emotions and may hinder communication, even if the prognosis is favorable."
            },
            {
              "id": "C",
              "text": "Option C: Children adopted internationally often have medical problems like this. is inappropriate because providing general information before addressing the parent\u0027s distress overlooks the emotional cue."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Let\u0027s first discuss the treatment plan, and we can address your concerns afterward. is inappropriate because deferring the emotional discussion misses an opportunity to build rapport and address the family\u0027s immediate concerns."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Are you feeling guilty because the rickets was not diagnosed sooner? is inappropriate because this closed, leading question supplies an interpretation before the father has described his concern. An open-ended invitation allows him to identify the meaning of his distress in his own words."
            },
            {
              "id": "B",
              "text": "Option B: Fortunately, this condition is very treatable, so there\u0027s no reason to be upset. is inappropriate because premature reassurance minimizes the father\u0027s emotions and may hinder communication, even if the prognosis is favorable."
            },
            {
              "id": "C",
              "text": "Option C: Children adopted internationally often have medical problems like this. is inappropriate because providing general information before addressing the parent\u0027s distress overlooks the emotional cue."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Are you feeling guilty because the rickets was not diagnosed sooner? is inappropriate because this closed, leading question supplies an interpretation before the father has described his concern. An open-ended invitation allows him to identify the meaning of his distress in his own words."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "I know exactly how you feel. is inappropriate because claiming exact understanding centers the physician and presumes equivalence with an experience the physician may not share. Empathy is better conveyed by eliciting and reflecting the father\u0027s experience."
            },
            {
              "id": "B",
              "text": "Option B: Fortunately, this condition is very treatable, so there\u0027s no reason to be upset. is inappropriate because premature reassurance minimizes the father\u0027s emotions and may hinder communication, even if the prognosis is favorable."
            },
            {
              "id": "C",
              "text": "Option C: Children adopted internationally often have medical problems like this. is inappropriate because providing general information before addressing the parent\u0027s distress overlooks the emotional cue."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "I know exactly how you feel. is inappropriate because claiming exact understanding centers the physician and presumes equivalence with an experience the physician may not share. Empathy is better conveyed by eliciting and reflecting the father\u0027s experience."
        }
      }
    },
    {
      "externalId": "step3-ethics-informed-refusal-capacity-733",
      "expectedHashes": {
        "ranaze_step3_uat": "d85088d8efd5d8d68adb7d20f22e14bd92fe2d39e5a4265214877b59bf4ea304"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "B",
              "text": "Option C: Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            },
            {
              "id": "C",
              "text": "Option D: Request a second surgical opinion before honoring the refusal is inappropriate because a second surgical opinion does not address the ethical issue of whether the patient has decision-making capacity to refuse treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            },
            {
              "id": "B",
              "text": "Option B: Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option D: Request a second surgical opinion before honoring the refusal is inappropriate because a second surgical opinion does not address the ethical issue of whether the patient has decision-making capacity to refuse treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Request a second surgical opinion before honoring the refusal is inappropriate because a second surgical opinion does not address the ethical issue of whether the patient has decision-making capacity to refuse treatment."
            },
            {
              "id": "B",
              "text": "Option B: Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Request a second surgical opinion before honoring the refusal is inappropriate because a second surgical opinion does not address the ethical issue of whether the patient has decision-making capacity to refuse treatment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed directly with comfort-focused care because the patient declined surgery is inappropriate because comfort-focused care may ultimately be appropriate if a patient with decision-making capacity continues to refuse surgery, but capacity must first be assessed."
            },
            {
              "id": "B",
              "text": "Option B: Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed directly with comfort-focused care because the patient declined surgery is inappropriate because comfort-focused care may ultimately be appropriate if a patient with decision-making capacity continues to refuse surgery, but capacity must first be assessed."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Declare that the patient lacks decision-making capacity because he refuses life-saving treatment is inappropriate because refusing a recommended life-saving intervention does not by itself demonstrate incapacity. Capacity depends on the patient\u0027s ability to understand, appreciate consequences, reason about options, and communicate a choice, so these abilities must be assessed directly."
            },
            {
              "id": "B",
              "text": "Option B: Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Declare that the patient lacks decision-making capacity because he refuses life-saving treatment is inappropriate because refusing a recommended life-saving intervention does not by itself demonstrate incapacity. Capacity depends on the patient\u0027s ability to understand, appreciate consequences, reason about options, and communicate a choice, so these abilities must be assessed directly."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a psychiatric consultation before attempting to assess his decision-making capacity is inappropriate because the treating physician can and should perform the initial decision-specific capacity assessment. Psychiatric consultation may help when mental illness or persistent diagnostic uncertainty complicates the evaluation, but it is not a prerequisite and should not delay this urgent assessment."
            },
            {
              "id": "B",
              "text": "Option B: Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a psychiatric consultation before attempting to assess his decision-making capacity is inappropriate because the treating physician can and should perform the initial decision-specific capacity assessment. Psychiatric consultation may help when mental illness or persistent diagnostic uncertainty complicates the evaluation, but it is not a prerequisite and should not delay this urgent assessment."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Proceed with amputation under the emergency exception to informed consent is inappropriate because the emergency exception permits treatment without consent when an urgent decision is required, the patient cannot participate, and no surrogate is available. This patient is communicating an explicit refusal and his capacity has not been assessed; the exception cannot be used merely because clinicians believe surgery is beneficial."
            },
            {
              "id": "B",
              "text": "Option B: Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Proceed with amputation under the emergency exception to informed consent is inappropriate because the emergency exception permits treatment without consent when an urgent decision is required, the patient cannot participate, and no surrogate is available. This patient is communicating an explicit refusal and his capacity has not been assessed; the exception cannot be used merely because clinicians believe surgery is beneficial."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer a brief orientation or cognitive screening test and honor the refusal if he passes is inappropriate because orientation and general cognitive screens do not alone establish decision-specific capacity. The clinician must evaluate understanding of the proposed amputation, appreciation of likely death without it, reasoning in light of the patient\u0027s values, and ability to communicate a stable choice."
            },
            {
              "id": "B",
              "text": "Option B: Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer a brief orientation or cognitive screening test and honor the refusal if he passes is inappropriate because orientation and general cognitive screens do not alone establish decision-specific capacity. The clinician must evaluate understanding of the proposed amputation, appreciation of likely death without it, reasoning in light of the patient\u0027s values, and ability to communicate a stable choice."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay the capacity assessment until antibiotics have treated the acute infection is inappropriate because capacity is assessed for the particular decision at the time it must be made. Because the infection is urgent and potentially fatal, the clinician should assess now while treating reversible contributors rather than postpone the evaluation until antibiotics have taken effect."
            },
            {
              "id": "B",
              "text": "Option B: Accept the wife\u0027s consent and proceed with amputation is inappropriate because a surrogate cannot override the informed refusal of a patient who has decision-making capacity."
            },
            {
              "id": "C",
              "text": "Option C: Obtain an emergency court order authorizing surgery is inappropriate because court intervention is generally reserved for patients who lack decision-making capacity and have no appropriate surrogate or when legal issues remain unresolved."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay the capacity assessment until antibiotics have treated the acute infection is inappropriate because capacity is assessed for the particular decision at the time it must be made. Because the infection is urgent and potentially fatal, the clinician should assess now while treating reversible contributors rather than postpone the evaluation until antibiotics have taken effect."
        }
      }
    },
    {
      "externalId": "step3-ethics-prenatal-counseling-shared-decision-making-1496",
      "expectedHashes": {
        "ranaze_step3_uat": "61546dfe0e4fbeac7860ede633147d5a3458cad221aa21a245e9907075c601bf",
        "ranaze_step3_prd": "61546dfe0e4fbeac7860ede633147d5a3458cad221aa21a245e9907075c601bf"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "B",
              "text": "Option C: Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            },
            {
              "id": "C",
              "text": "Option D: Have either of you already decided whether you would continue the pregnancy if a chromosomal disorder were confirmed? is inappropriate because exploring future reproductive decisions is important but is premature before addressing the couple\u0027s immediate emotional response and understanding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            },
            {
              "id": "B",
              "text": "Option B: Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "C",
              "text": "Option D: Have either of you already decided whether you would continue the pregnancy if a chromosomal disorder were confirmed? is inappropriate because exploring future reproductive decisions is important but is premature before addressing the couple\u0027s immediate emotional response and understanding."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Have either of you already decided whether you would continue the pregnancy if a chromosomal disorder were confirmed? is inappropriate because exploring future reproductive decisions is important but is premature before addressing the couple\u0027s immediate emotional response and understanding."
            },
            {
              "id": "B",
              "text": "Option B: Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "C",
              "text": "Option C: Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Have either of you already decided whether you would continue the pregnancy if a chromosomal disorder were confirmed? is inappropriate because exploring future reproductive decisions is important but is premature before addressing the couple\u0027s immediate emotional response and understanding."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The mother will make the final decision, so let\u0027s hear only her opinion first. is inappropriate because although the pregnant patient ultimately provides informed consent, excluding her partner from the discussion does not promote effective communication or shared decision-making."
            },
            {
              "id": "B",
              "text": "Option B: Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "C",
              "text": "Option C: Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The mother will make the final decision, so let\u0027s hear only her opinion first. is inappropriate because although the pregnant patient ultimately provides informed consent, excluding her partner from the discussion does not promote effective communication or shared decision-making."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Try not to worry; an abnormal screening result usually does not mean that the fetus has trisomy 21. is inappropriate because this offers premature reassurance and assumes what the patient fears before asking. Screening is not diagnostic, but the physician should first acknowledge the distress and invite both individuals to describe their concerns."
            },
            {
              "id": "B",
              "text": "Option B: Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "C",
              "text": "Option C: Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Try not to worry; an abnormal screening result usually does not mean that the fetus has trisomy 21. is inappropriate because this offers premature reassurance and assumes what the patient fears before asking. Screening is not diagnostic, but the physician should first acknowledge the distress and invite both individuals to describe their concerns."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Let me first explain the risks of miscarriage and other complications from amniocentesis. is inappropriate because procedural risks are essential to informed consent, but immediately delivering technical information bypasses the patient\u0027s tearfulness and the couple\u0027s conflict. Empathic exploration should precede detailed counseling."
            },
            {
              "id": "B",
              "text": "Option B: Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "C",
              "text": "Option C: Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Let me first explain the risks of miscarriage and other complications from amniocentesis. is inappropriate because procedural risks are essential to informed consent, but immediately delivering technical information bypasses the patient\u0027s tearfulness and the couple\u0027s conflict. Empathic exploration should precede detailed counseling."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Please try not to argue; conflict will only make this decision more difficult. is inappropriate because telling the couple not to argue is judgmental and suppresses rather than explores disagreement. The physician should validate the difficulty and use open-ended questions."
            },
            {
              "id": "B",
              "text": "Option B: Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "C",
              "text": "Option C: Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Please try not to argue; conflict will only make this decision more difficult. is inappropriate because telling the couple not to argue is judgmental and suppresses rather than explores disagreement. The physician should validate the difficulty and use open-ended questions."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "I will arrange for a genetic counselor to discuss the result with you instead. is inappropriate because genetic-counselor referral is appropriate after a positive prenatal screen, but it does not excuse the physician from responding to the immediate emotional cue. The physician should acknowledge and explore concerns before arranging further counseling."
            },
            {
              "id": "B",
              "text": "Option B: Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "C",
              "text": "Option C: Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "I will arrange for a genetic counselor to discuss the result with you instead. is inappropriate because genetic-counselor referral is appropriate after a positive prenatal screen, but it does not excuse the physician from responding to the immediate emotional cue. The physician should acknowledge and explore concerns before arranging further counseling."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Would you prefer to have cell-free DNA screening instead of amniocentesis? is inappropriate because cell-free DNA screening can be an option after a positive serum screen for a patient wishing to avoid an invasive test, but offering another test immediately is premature while the couple\u0027s emotions, understanding, and goals remain unexplored."
            },
            {
              "id": "B",
              "text": "Option B: Because the screening test is abnormal, I recommend scheduling amniocentesis today. is inappropriate because amniocentesis is optional after a positive screening test. The physician should first explore the couple\u0027s understanding, emotions, and goals before making recommendations."
            },
            {
              "id": "C",
              "text": "Option C: Let\u0027s repeat the maternal serum screening before making any decisions. is inappropriate because maternal serum screening is a screening test and is not typically repeated to resolve an abnormal result; diagnostic testing is offered instead."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Would you prefer to have cell-free DNA screening instead of amniocentesis? is inappropriate because cell-free DNA screening can be an option after a positive serum screen for a patient wishing to avoid an invasive test, but offering another test immediately is premature while the couple\u0027s emotions, understanding, and goals remain unexplored."
        }
      }
    },
    {
      "externalId": "step3-gastro-sbp-saag-241",
      "expectedHashes": {
        "ranaze_step3_uat": "6e573bb46a93c69b7ad7ebb8917340e9dca4f35b0c971d05be3ffb4ec5fc20fa",
        "ranaze_step3_prd": "6e573bb46a93c69b7ad7ebb8917340e9dca4f35b0c971d05be3ffb4ec5fc20fa"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "B",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            },
            {
              "id": "C",
              "text": "Option D: Start oral doxycycline is inappropriate because doxycycline does not provide appropriate empiric coverage for the organisms that commonly cause spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option D: Start oral doxycycline is inappropriate because doxycycline does not provide appropriate empiric coverage for the organisms that commonly cause spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start oral doxycycline is inappropriate because doxycycline does not provide appropriate empiric coverage for the organisms that commonly cause spontaneous bacterial peritonitis."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start oral doxycycline is inappropriate because doxycycline does not provide appropriate empiric coverage for the organisms that commonly cause spontaneous bacterial peritonitis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule transjugular intrahepatic portosystemic shunt placement is inappropriate because tIPS may be considered for selected patients with refractory ascites but is not appropriate during active spontaneous bacterial peritonitis and may worsen encephalopathy."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule transjugular intrahepatic portosystemic shunt placement is inappropriate because tIPS may be considered for selected patients with refractory ascites but is not appropriate during active spontaneous bacterial peritonitis and may worsen encephalopathy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Await ascitic fluid culture results before starting antibiotics is inappropriate because an ascitic PMN count of 360/mm3 establishes neutrocytic ascites requiring immediate empiric treatment; culture negativity would not exclude SBP and culture results should not delay antibiotics."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Await ascitic fluid culture results before starting antibiotics is inappropriate because an ascitic PMN count of 360/mm3 establishes neutrocytic ascites requiring immediate empiric treatment; culture negativity would not exclude SBP and culture results should not delay antibiotics."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous albumin without antibiotics is inappropriate because albumin can be an adjunct to antibiotics in selected patients with SBP but has no antimicrobial activity and cannot be used alone. The stem does not provide the renal dysfunction or marked hyperbilirubinemia typically used to identify the greatest benefit from albumin."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous albumin without antibiotics is inappropriate because albumin can be an adjunct to antibiotics in selected patients with SBP but has no antimicrobial activity and cannot be used alone. The stem does not provide the renal dysfunction or marked hyperbilirubinemia typically used to identify the greatest benefit from albumin."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start oral ciprofloxacin for spontaneous bacterial peritonitis prophylaxis is inappropriate because oral fluoroquinolone prophylaxis is intended to prevent SBP in selected high-risk patients or after recovery from an episode. It is not adequate treatment for active SBP documented by a PMN count of 360/mm3."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start oral ciprofloxacin for spontaneous bacterial peritonitis prophylaxis is inappropriate because oral fluoroquinolone prophylaxis is intended to prevent SBP in selected high-risk patients or after recovery from an episode. It is not adequate treatment for active SBP documented by a PMN count of 360/mm3."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin intravenous vancomycin monotherapy is inappropriate because vancomycin alone targets gram-positive organisms and does not provide appropriate empiric coverage for community-acquired SBP, in which enteric gram-negative organisms must be covered."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin intravenous vancomycin monotherapy is inappropriate because vancomycin alone targets gram-positive organisms and does not provide appropriate empiric coverage for community-acquired SBP, in which enteric gram-negative organisms must be covered."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain abdominal CT and request surgical consultation before starting treatment is inappropriate because the absence of rebound or guarding and the low ascitic protein support uncomplicated portal-hypertensive ascites with SBP rather than a perforated viscus or other evident surgical source. Imaging must not delay empiric antibiotics after a diagnostic PMN count above 250/mm3."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain abdominal CT and request surgical consultation before starting treatment is inappropriate because the absence of rebound or guarding and the low ascitic protein support uncomplicated portal-hypertensive ascites with SBP rather than a perforated viscus or other evident surgical source. Imaging must not delay empiric antibiotics after a diagnostic PMN count above 250/mm3."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase lactulose therapy and reassess after the confusion resolves is inappropriate because mild confusion may reflect infection-precipitated hepatic encephalopathy, but increasing lactulose does not treat the underlying ascitic infection. Antibiotics are the immediate priority."
            },
            {
              "id": "B",
              "text": "Option B: Increase the doses of spironolactone and furosemide is inappropriate because increasing diuretics may help uncomplicated ascites but does not treat infected ascitic fluid."
            },
            {
              "id": "C",
              "text": "Option C: Perform therapeutic large-volume paracentesis only is inappropriate because large-volume paracentesis can relieve tense ascites but is not adequate treatment for spontaneous bacterial peritonitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase lactulose therapy and reassess after the confusion resolves is inappropriate because mild confusion may reflect infection-precipitated hepatic encephalopathy, but increasing lactulose does not treat the underlying ascitic infection. Antibiotics are the immediate priority."
        }
      }
    },
    {
      "externalId": "step3-gastroenterology-peptic-ulcer-prognosis-905",
      "expectedHashes": {
        "ranaze_step3_uat": "675186fb1fca7db5aff993560076f6424b9f11344bee7065f2d4759d0632a529",
        "ranaze_step3_prd": "675186fb1fca7db5aff993560076f6424b9f11344bee7065f2d4759d0632a529"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He will probably require surgical resection because gastric ulcers rarely heal medically is inappropriate because surgery is reserved for complications such as perforation, uncontrolled bleeding, obstruction, or refractory disease."
            },
            {
              "id": "B",
              "text": "Option C: He is unlikely to develop another ulcer even if the infection is not eradicated is inappropriate because persistent H. pylori infection is associated with recurrent peptic ulcer disease, so recurrence risk remains elevated without eradication."
            },
            {
              "id": "C",
              "text": "Option D: Long-term recovery requires permanent suppression of gastric acid secretion is inappropriate because lifelong acid suppression is generally unnecessary after successful H. pylori eradication unless another ongoing indication exists."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He will probably require surgical resection because gastric ulcers rarely heal medically is inappropriate because surgery is reserved for complications such as perforation, uncontrolled bleeding, obstruction, or refractory disease."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He is unlikely to develop another ulcer even if the infection is not eradicated is inappropriate because persistent H. pylori infection is associated with recurrent peptic ulcer disease, so recurrence risk remains elevated without eradication."
            },
            {
              "id": "B",
              "text": "Option B: He will probably require surgical resection because gastric ulcers rarely heal medically is inappropriate because surgery is reserved for complications such as perforation, uncontrolled bleeding, obstruction, or refractory disease."
            },
            {
              "id": "C",
              "text": "Option D: Long-term recovery requires permanent suppression of gastric acid secretion is inappropriate because lifelong acid suppression is generally unnecessary after successful H. pylori eradication unless another ongoing indication exists."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He is unlikely to develop another ulcer even if the infection is not eradicated is inappropriate because persistent H. pylori infection is associated with recurrent peptic ulcer disease, so recurrence risk remains elevated without eradication."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long-term recovery requires permanent suppression of gastric acid secretion is inappropriate because lifelong acid suppression is generally unnecessary after successful H. pylori eradication unless another ongoing indication exists."
            },
            {
              "id": "B",
              "text": "Option B: He will probably require surgical resection because gastric ulcers rarely heal medically is inappropriate because surgery is reserved for complications such as perforation, uncontrolled bleeding, obstruction, or refractory disease."
            },
            {
              "id": "C",
              "text": "Option C: He is unlikely to develop another ulcer even if the infection is not eradicated is inappropriate because persistent H. pylori infection is associated with recurrent peptic ulcer disease, so recurrence risk remains elevated without eradication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long-term recovery requires permanent suppression of gastric acid secretion is inappropriate because lifelong acid suppression is generally unnecessary after successful H. pylori eradication unless another ongoing indication exists."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "His future children will have a high inherited risk of developing the same lesion is inappropriate because peptic ulcers are not inherited in a simple Mendelian pattern, and the lesion is linked to an acquired infection."
            },
            {
              "id": "B",
              "text": "Option B: He will probably require surgical resection because gastric ulcers rarely heal medically is inappropriate because surgery is reserved for complications such as perforation, uncontrolled bleeding, obstruction, or refractory disease."
            },
            {
              "id": "C",
              "text": "Option C: He is unlikely to develop another ulcer even if the infection is not eradicated is inappropriate because persistent H. pylori infection is associated with recurrent peptic ulcer disease, so recurrence risk remains elevated without eradication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "His future children will have a high inherited risk of developing the same lesion is inappropriate because peptic ulcers are not inherited in a simple Mendelian pattern, and the lesion is linked to an acquired infection."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "He will require annual surveillance endoscopy for the remainder of his life is inappropriate because a gastric ulcer may warrant follow-up endoscopy based on its appearance, biopsy adequacy, symptoms, risk factors, and response, but a benign ulcer in a young patient does not automatically mandate annual lifelong endoscopy."
            },
            {
              "id": "B",
              "text": "Option B: He will probably require surgical resection because gastric ulcers rarely heal medically is inappropriate because surgery is reserved for complications such as perforation, uncontrolled bleeding, obstruction, or refractory disease."
            },
            {
              "id": "C",
              "text": "Option C: He is unlikely to develop another ulcer even if the infection is not eradicated is inappropriate because persistent H. pylori infection is associated with recurrent peptic ulcer disease, so recurrence risk remains elevated without eradication."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "He will require annual surveillance endoscopy for the remainder of his life is inappropriate because a gastric ulcer may warrant follow-up endoscopy based on its appearance, biopsy adequacy, symptoms, risk factors, and response, but a benign ulcer in a young patient does not automatically mandate annual lifelong endoscopy."
        }
      }
    },
    {
      "externalId": "step3-gastroenterology-unintentional-weight-loss-abdominal-ct-1996",
      "expectedHashes": {
        "ranaze_step3_uat": "9e191812fb3318aefb0893f61b4bd0bddc7be68fce5c6022d8ea194ee12e0cea",
        "ranaze_step3_prd": "9e191812fb3318aefb0893f61b4bd0bddc7be68fce5c6022d8ea194ee12e0cea"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Screening colonoscopy is inappropriate because colonoscopy may eventually be indicated based on screening history or colorectal symptoms, but it does not evaluate the liver, pancreas, biliary tract, lymph nodes, or other potential causes suggested by this presentation."
            },
            {
              "id": "B",
              "text": "Option C: Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not sufficiently sensitive or specific for the initial diagnosis of an occult malignancy and should not replace imaging."
            },
            {
              "id": "C",
              "text": "Option D: Hepatobiliary ultrasonography is inappropriate because ultrasonography is useful for suspected gallstones or focused biliary obstruction but provides a narrower evaluation than CT and is less appropriate here without jaundice, right upper quadrant pain, or marked cholestasis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Screening colonoscopy is inappropriate because colonoscopy may eventually be indicated based on screening history or colorectal symptoms, but it does not evaluate the liver, pancreas, biliary tract, lymph nodes, or other potential causes suggested by this presentation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not sufficiently sensitive or specific for the initial diagnosis of an occult malignancy and should not replace imaging."
            },
            {
              "id": "B",
              "text": "Option B: Screening colonoscopy is inappropriate because colonoscopy may eventually be indicated based on screening history or colorectal symptoms, but it does not evaluate the liver, pancreas, biliary tract, lymph nodes, or other potential causes suggested by this presentation."
            },
            {
              "id": "C",
              "text": "Option D: Hepatobiliary ultrasonography is inappropriate because ultrasonography is useful for suspected gallstones or focused biliary obstruction but provides a narrower evaluation than CT and is less appropriate here without jaundice, right upper quadrant pain, or marked cholestasis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not sufficiently sensitive or specific for the initial diagnosis of an occult malignancy and should not replace imaging."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hepatobiliary ultrasonography is inappropriate because ultrasonography is useful for suspected gallstones or focused biliary obstruction but provides a narrower evaluation than CT and is less appropriate here without jaundice, right upper quadrant pain, or marked cholestasis."
            },
            {
              "id": "B",
              "text": "Option B: Screening colonoscopy is inappropriate because colonoscopy may eventually be indicated based on screening history or colorectal symptoms, but it does not evaluate the liver, pancreas, biliary tract, lymph nodes, or other potential causes suggested by this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not sufficiently sensitive or specific for the initial diagnosis of an occult malignancy and should not replace imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hepatobiliary ultrasonography is inappropriate because ultrasonography is useful for suspected gallstones or focused biliary obstruction but provides a narrower evaluation than CT and is less appropriate here without jaundice, right upper quadrant pain, or marked cholestasis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radionuclide liver and spleen scanning has limited anatomic detail and has largely been replaced by CT or MRI for evaluation of suspected intra-abdominal malignancy."
            },
            {
              "id": "B",
              "text": "Option B: Screening colonoscopy is inappropriate because colonoscopy may eventually be indicated based on screening history or colorectal symptoms, but it does not evaluate the liver, pancreas, biliary tract, lymph nodes, or other potential causes suggested by this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not sufficiently sensitive or specific for the initial diagnosis of an occult malignancy and should not replace imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radionuclide liver and spleen scanning has limited anatomic detail and has largely been replaced by CT or MRI for evaluation of suspected intra-abdominal malignancy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contrast-enhanced CT scan of the chest is inappropriate because chest CT could detect a thoracic malignancy, but she has early satiety and abnormal AST, ALT, and alkaline phosphatase without respiratory findings. It would omit the abdominal and pelvic structures most strongly implicated by the available evidence."
            },
            {
              "id": "B",
              "text": "Option B: Screening colonoscopy is inappropriate because colonoscopy may eventually be indicated based on screening history or colorectal symptoms, but it does not evaluate the liver, pancreas, biliary tract, lymph nodes, or other potential causes suggested by this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not sufficiently sensitive or specific for the initial diagnosis of an occult malignancy and should not replace imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contrast-enhanced CT scan of the chest is inappropriate because chest CT could detect a thoracic malignancy, but she has early satiety and abnormal AST, ALT, and alkaline phosphatase without respiratory findings. It would omit the abdominal and pelvic structures most strongly implicated by the available evidence."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gastric emptying scintigraphy is appropriate when gastroparesis is suspected, typically from compatible nausea, vomiting, postprandial fullness, or a predisposing condition. It would not broadly evaluate the malignancies suggested by rapid weight loss and abnormal liver tests."
            },
            {
              "id": "B",
              "text": "Option B: Screening colonoscopy is inappropriate because colonoscopy may eventually be indicated based on screening history or colorectal symptoms, but it does not evaluate the liver, pancreas, biliary tract, lymph nodes, or other potential causes suggested by this presentation."
            },
            {
              "id": "C",
              "text": "Option C: Serum carcinoembryonic antigen measurement is inappropriate because carcinoembryonic antigen is not sufficiently sensitive or specific for the initial diagnosis of an occult malignancy and should not replace imaging."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gastric emptying scintigraphy is appropriate when gastroparesis is suspected, typically from compatible nausea, vomiting, postprandial fullness, or a predisposing condition. It would not broadly evaluate the malignancies suggested by rapid weight loss and abnormal liver tests."
        }
      }
    },
    {
      "externalId": "step3-geriatrics-resistance-training-functional-status-1875",
      "expectedHashes": {
        "ranaze_step3_uat": "8360dd534c862b3884fab915003a9b13f2f09e14596e3db4e7ad38cd236b39a3",
        "ranaze_step3_prd": "8360dd534c862b3884fab915003a9b13f2f09e14596e3db4e7ad38cd236b39a3"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Improved endurance without a significant reduction in fall risk is inappropriate because multicomponent exercise improves both endurance and balance, leading to a meaningful reduction in fall risk."
            },
            {
              "id": "B",
              "text": "Option C: Improved muscle strength only if high-calorie nutritional supplementation is added is inappropriate because although nutritional support may be appropriate for malnourished patients, exercise alone improves strength and function in most older adults."
            },
            {
              "id": "C",
              "text": "Option D: Improved psychological well-being without measurable physical benefit is inappropriate because exercise provides substantial physical benefits in addition to psychological benefits."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Improved endurance without a significant reduction in fall risk is inappropriate because multicomponent exercise improves both endurance and balance, leading to a meaningful reduction in fall risk."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Improved muscle strength only if high-calorie nutritional supplementation is added is inappropriate because although nutritional support may be appropriate for malnourished patients, exercise alone improves strength and function in most older adults."
            },
            {
              "id": "B",
              "text": "Option B: Improved endurance without a significant reduction in fall risk is inappropriate because multicomponent exercise improves both endurance and balance, leading to a meaningful reduction in fall risk."
            },
            {
              "id": "C",
              "text": "Option D: Improved psychological well-being without measurable physical benefit is inappropriate because exercise provides substantial physical benefits in addition to psychological benefits."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Improved muscle strength only if high-calorie nutritional supplementation is added is inappropriate because although nutritional support may be appropriate for malnourished patients, exercise alone improves strength and function in most older adults."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Improved psychological well-being without measurable physical benefit is inappropriate because exercise provides substantial physical benefits in addition to psychological benefits."
            },
            {
              "id": "B",
              "text": "Option B: Improved endurance without a significant reduction in fall risk is inappropriate because multicomponent exercise improves both endurance and balance, leading to a meaningful reduction in fall risk."
            },
            {
              "id": "C",
              "text": "Option C: Improved muscle strength only if high-calorie nutritional supplementation is added is inappropriate because although nutritional support may be appropriate for malnourished patients, exercise alone improves strength and function in most older adults."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Improved psychological well-being without measurable physical benefit is inappropriate because exercise provides substantial physical benefits in addition to psychological benefits."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Improved muscle strength without improvement in activities of daily living is inappropriate because improved strength generally translates into improved performance of activities of daily living and mobility."
            },
            {
              "id": "B",
              "text": "Option B: Improved endurance without a significant reduction in fall risk is inappropriate because multicomponent exercise improves both endurance and balance, leading to a meaningful reduction in fall risk."
            },
            {
              "id": "C",
              "text": "Option C: Improved muscle strength only if high-calorie nutritional supplementation is added is inappropriate because although nutritional support may be appropriate for malnourished patients, exercise alone improves strength and function in most older adults."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Improved muscle strength without improvement in activities of daily living is inappropriate because improved strength generally translates into improved performance of activities of daily living and mobility."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increased fracture risk that outweighs benefit because osteoporosis contraindicates resistance exercise is inappropriate because osteoporosis increases the consequences of falling but is not a blanket contraindication to supervised progressive resistance and balance exercise. Such training improves strength and balance and helps reduce falls and fall-related injuries."
            },
            {
              "id": "B",
              "text": "Option B: Improved endurance without a significant reduction in fall risk is inappropriate because multicomponent exercise improves both endurance and balance, leading to a meaningful reduction in fall risk."
            },
            {
              "id": "C",
              "text": "Option C: Improved muscle strength only if high-calorie nutritional supplementation is added is inappropriate because although nutritional support may be appropriate for malnourished patients, exercise alone improves strength and function in most older adults."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increased fracture risk that outweighs benefit because osteoporosis contraindicates resistance exercise is inappropriate because osteoporosis increases the consequences of falling but is not a blanket contraindication to supervised progressive resistance and balance exercise. Such training improves strength and balance and helps reduce falls and fall-related injuries."
        }
      }
    },
    {
      "externalId": "step3-gi-acute-mesenteric-ischemia-814",
      "expectedHashes": {
        "ranaze_step3_uat": "7543fae780bf1516548792279784696ddf3031a4e96efad3b553b321f58321a5",
        "ranaze_step3_prd": "7543fae780bf1516548792279784696ddf3031a4e96efad3b553b321f58321a5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "B",
              "text": "Option C: Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            },
            {
              "id": "C",
              "text": "Option D: Contrast-enhanced CT of the abdomen without vascular imaging is inappropriate because routine portal venous phase CT may identify bowel abnormalities but is less informative than a dedicated CTA protocol for identifying mesenteric vascular occlusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option D: Contrast-enhanced CT of the abdomen without vascular imaging is inappropriate because routine portal venous phase CT may identify bowel abnormalities but is less informative than a dedicated CTA protocol for identifying mesenteric vascular occlusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contrast-enhanced CT of the abdomen without vascular imaging is inappropriate because routine portal venous phase CT may identify bowel abnormalities but is less informative than a dedicated CTA protocol for identifying mesenteric vascular occlusion."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contrast-enhanced CT of the abdomen without vascular imaging is inappropriate because routine portal venous phase CT may identify bowel abnormalities but is less informative than a dedicated CTA protocol for identifying mesenteric vascular occlusion."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate exploratory laparotomy is inappropriate because immediate exploration is indicated when peritonitis or perforation suggests bowel infarction; those findings are absent here."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate exploratory laparotomy is inappropriate because immediate exploration is indicated when peritonitis or perforation suggests bowel infarction; those findings are absent here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Catheter-based mesenteric angiography is inappropriate because formal angiography can diagnose and sometimes treat mesenteric arterial occlusion, but multidetector CTA has replaced it as the preferred initial diagnostic study. Angiography is more invasive and should not precede rapidly available CTA in this stable patient."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Catheter-based mesenteric angiography is inappropriate because formal angiography can diagnose and sometimes treat mesenteric arterial occlusion, but multidetector CTA has replaced it as the preferred initial diagnostic study. Angiography is more invasive and should not precede rapidly available CTA in this stable patient."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MR angiography of the mesenteric vessels is inappropriate because mRA can depict mesenteric vessels and may appear attractive because creatinine is elevated, but its emergency use is limited by availability and acquisition time. Suspected acute mesenteric ischemia requires immediate CTA despite acute kidney injury."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MR angiography of the mesenteric vessels is inappropriate because mRA can depict mesenteric vessels and may appear attractive because creatinine is elevated, but its emergency use is limited by availability and acquisition time. Suspected acute mesenteric ischemia requires immediate CTA despite acute kidney injury."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Duplex Doppler ultrasonography of the mesenteric vessels is inappropriate because mesenteric duplex imaging is operator-dependent and has a limited role in acute mesenteric ischemia; bowel gas can further restrict visualization. It is used more often in chronic mesenteric ischemia and must not delay CTA."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Duplex Doppler ultrasonography of the mesenteric vessels is inappropriate because mesenteric duplex imaging is operator-dependent and has a limited role in acute mesenteric ischemia; bowel gas can further restrict visualization. It is used more often in chronic mesenteric ischemia and must not delay CTA."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Noncontrast CT of the abdomen and pelvis is inappropriate because noncontrast CT cannot adequately evaluate arterial patency or bowel-wall enhancement and is rated usually not appropriate for initial imaging of suspected acute mesenteric ischemia. The renal injury does not justify omitting IV contrast."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Noncontrast CT of the abdomen and pelvis is inappropriate because noncontrast CT cannot adequately evaluate arterial patency or bowel-wall enhancement and is rated usually not appropriate for initial imaging of suspected acute mesenteric ischemia. The renal injury does not justify omitting IV contrast."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A single serum lactate measurement, with acute mesenteric ischemia excluded if the result is normal is inappropriate because no single serum lactate measurement is sufficiently sensitive or specific to establish or exclude acute mesenteric ischemia. Lactate may remain normal early in the disease and may be elevated for other reasons, including hypoperfusion or dehydration. This patient\u00E2\u20AC\u2122s sudden severe pain out of proportion to examination and new atrial fibrillation require prompt CT angiography regardless of a single lactate value."
            },
            {
              "id": "B",
              "text": "Option B: Colonoscopy evaluates colonic pathology but delays diagnosis and may increase risk in suspected acute mesenteric ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Upper endoscopy is appropriate for selected causes of upper gastrointestinal bleeding but does not evaluate mesenteric arterial perfusion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A single serum lactate measurement, with acute mesenteric ischemia excluded if the result is normal is inappropriate because no single serum lactate measurement is sufficiently sensitive or specific to establish or exclude acute mesenteric ischemia. Lactate may remain normal early in the disease and may be elevated for other reasons, including hypoperfusion or dehydration. This patient\u00E2\u20AC\u2122s sudden severe pain out of proportion to examination and new atrial fibrillation require prompt CT angiography regardless of a single lactate value."
        }
      }
    },
    {
      "externalId": "step3-heartfailure-aldosterone-antagonist-884",
      "expectedHashes": {
        "ranaze_step3_uat": "ce2cdb1a45867d5adec25c7c873f1f2e37131dba4062b1a1b4892ed0305e3c51",
        "ranaze_step3_prd": "ce2cdb1a45867d5adec25c7c873f1f2e37131dba4062b1a1b4892ed0305e3c51"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "B",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            },
            {
              "id": "C",
              "text": "Option D: Digoxin may reduce heart failure hospitalizations and improve symptoms but does not reduce mortality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
        },
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option D: Digoxin may reduce heart failure hospitalizations and improve symptoms but does not reduce mortality."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Digoxin may reduce heart failure hospitalizations and improve symptoms but does not reduce mortality."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Digoxin may reduce heart failure hospitalizations and improve symptoms but does not reduce mortality."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Mexiletine can suppress ventricular arrhythmias but does not improve survival in chronic heart failure."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Mexiletine can suppress ventricular arrhythmias but does not improve survival in chronic heart failure."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ivabradine can reduce heart-failure hospitalization in selected symptomatic HFrEF patients in sinus rhythm whose resting heart rate remains at least 70/min despite maximally tolerated beta-blockade. Her pulse is already 68/min, and ivabradine is not a substitute for the missing mortality-reducing mineralocorticoid receptor antagonist."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ivabradine can reduce heart-failure hospitalization in selected symptomatic HFrEF patients in sinus rhythm whose resting heart rate remains at least 70/min despite maximally tolerated beta-blockade. Her pulse is already 68/min, and ivabradine is not a substitute for the missing mortality-reducing mineralocorticoid receptor antagonist."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Enalapril added to sacubitril/valsartan is inappropriate because an ACE inhibitor must not be administered concurrently with sacubitril/valsartan; a 36-hour washout is required because concomitant neprilysin and ACE inhibition increases angioedema risk. Enalapril would replace\u00E2\u20AC\u201Dnot supplement\u00E2\u20AC\u201Dthe ARNI and would not complete the four foundational HFrEF drug classes."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Enalapril added to sacubitril/valsartan is inappropriate because an ACE inhibitor must not be administered concurrently with sacubitril/valsartan; a 36-hour washout is required because concomitant neprilysin and ACE inhibition increases angioedema risk. Enalapril would replace\u00E2\u20AC\u201Dnot supplement\u00E2\u20AC\u201Dthe ARNI and would not complete the four foundational HFrEF drug classes."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Losartan added to sacubitril/valsartan is inappropriate because sacubitril/valsartan already supplies the ARB valsartan. Adding losartan would duplicate renin-angiotensin receptor blockade without establishing additional survival benefit and would increase the risks of hypotension, renal dysfunction, and hyperkalemia."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Losartan added to sacubitril/valsartan is inappropriate because sacubitril/valsartan already supplies the ARB valsartan. Adding losartan would duplicate renin-angiotensin receptor blockade without establishing additional survival benefit and would increase the risks of hypotension, renal dysfunction, and hyperkalemia."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Empagliflozin added to dapagliflozin is inappropriate because dapagliflozin and empagliflozin are both SGLT2 inhibitors. Evidence supports using one agent from this class in HFrEF, not combining two; dual therapy would add adverse-effect risk without completing the missing MRA component of guideline-directed therapy."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Empagliflozin added to dapagliflozin is inappropriate because dapagliflozin and empagliflozin are both SGLT2 inhibitors. Evidence supports using one agent from this class in HFrEF, not combining two; dual therapy would add adverse-effect risk without completing the missing MRA component of guideline-directed therapy."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amlodipine may be used when another indication such as hypertension or angina exists, but it does not provide an established survival benefit in HFrEF. This patient is normotensive and has no obstructive coronary disease."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amlodipine may be used when another indication such as hypertension or angina exists, but it does not provide an established survival benefit in HFrEF. This patient is normotensive and has no obstructive coronary disease."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Flecainide is a class Ic antiarrhythmic that can be proarrhythmic in significant structural heart disease. Suppressing brief asymptomatic nonsustained VT with flecainide would not improve survival and is particularly inappropriate in dilated cardiomyopathy with an ejection fraction of 28%."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Flecainide is a class Ic antiarrhythmic that can be proarrhythmic in significant structural heart disease. Suppressing brief asymptomatic nonsustained VT with flecainide would not improve survival and is particularly inappropriate in dilated cardiomyopathy with an ejection fraction of 28%."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspirin is indicated for appropriate atherosclerotic or thrombotic disease, not simply for low ejection fraction. Her angiogram shows no obstructive coronary disease, and aspirin does not improve survival from nonischemic HFrEF."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspirin is indicated for appropriate atherosclerotic or thrombotic disease, not simply for low ejection fraction. Her angiogram shows no obstructive coronary disease, and aspirin does not improve survival from nonischemic HFrEF."
        },
        "M": {
          "prompt": "Which feature of option M should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vericiguat may be considered in selected high-risk patients with recent worsening HFrEF despite guideline-directed therapy to reduce subsequent events, particularly hospitalization. It is a secondary option rather than a substitute for the missing class I MRA, whose morbidity and mortality benefit is established in eligible symptomatic HFrEF."
            },
            {
              "id": "B",
              "text": "Option A: Amiodarone can suppress ventricular arrhythmias but does not provide the established mortality benefit of completing guideline-directed HFrEF therapy in this setting."
            },
            {
              "id": "C",
              "text": "Option B: Diltiazem is inappropriate because non-dihydropyridine calcium channel blockers have negative inotropic effects and should generally be avoided in HFrEF."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vericiguat may be considered in selected high-risk patients with recent worsening HFrEF despite guideline-directed therapy to reduce subsequent events, particularly hospitalization. It is a secondary option rather than a substitute for the missing class I MRA, whose morbidity and mortality benefit is established in eligible symptomatic HFrEF."
        }
      }
    },
    {
      "externalId": "step3-hematology-multiple-myeloma-hypercalcemia-treatment-918",
      "expectedHashes": {
        "ranaze_step3_uat": "7fc8ab4312a2cfca64a43a41db9bdeb4b459914a8b59bd2bb3a9c131294ac349",
        "ranaze_step3_prd": "7fc8ab4312a2cfca64a43a41db9bdeb4b459914a8b59bd2bb3a9c131294ac349"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Emergent hemodialysis is inappropriate because hemodialysis is reserved for severe, refractory hypercalcemia or patients who cannot tolerate aggressive hydration due to advanced renal failure or heart failure."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous mannitol is inappropriate because mannitol is not used to treat hypercalcemia and may worsen volume depletion."
            },
            {
              "id": "C",
              "text": "Option D: Transfusion of packed red blood cells is inappropriate because although the patient is anemic, a hemoglobin of 10.2 g/dL does not require urgent transfusion and does not address the immediate life-threatening problem."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Emergent hemodialysis is inappropriate because hemodialysis is reserved for severe, refractory hypercalcemia or patients who cannot tolerate aggressive hydration due to advanced renal failure or heart failure."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous mannitol is inappropriate because mannitol is not used to treat hypercalcemia and may worsen volume depletion."
            },
            {
              "id": "B",
              "text": "Option B: Emergent hemodialysis is inappropriate because hemodialysis is reserved for severe, refractory hypercalcemia or patients who cannot tolerate aggressive hydration due to advanced renal failure or heart failure."
            },
            {
              "id": "C",
              "text": "Option D: Transfusion of packed red blood cells is inappropriate because although the patient is anemic, a hemoglobin of 10.2 g/dL does not require urgent transfusion and does not address the immediate life-threatening problem."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous mannitol is inappropriate because mannitol is not used to treat hypercalcemia and may worsen volume depletion."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transfusion of packed red blood cells is inappropriate because although the patient is anemic, a hemoglobin of 10.2 g/dL does not require urgent transfusion and does not address the immediate life-threatening problem."
            },
            {
              "id": "B",
              "text": "Option B: Emergent hemodialysis is inappropriate because hemodialysis is reserved for severe, refractory hypercalcemia or patients who cannot tolerate aggressive hydration due to advanced renal failure or heart failure."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous mannitol is inappropriate because mannitol is not used to treat hypercalcemia and may worsen volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transfusion of packed red blood cells is inappropriate because although the patient is anemic, a hemoglobin of 10.2 g/dL does not require urgent transfusion and does not address the immediate life-threatening problem."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Platelet transfusion is generally reserved for active bleeding or severe thrombocytopenia, not a platelet count of 72,000/mm3 without bleeding."
            },
            {
              "id": "B",
              "text": "Option B: Emergent hemodialysis is inappropriate because hemodialysis is reserved for severe, refractory hypercalcemia or patients who cannot tolerate aggressive hydration due to advanced renal failure or heart failure."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous mannitol is inappropriate because mannitol is not used to treat hypercalcemia and may worsen volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Platelet transfusion is generally reserved for active bleeding or severe thrombocytopenia, not a platelet count of 72,000/mm3 without bleeding."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcutaneous calcitonin as sole therapy is inappropriate because calcitonin has a rapid but short-lived calcium-lowering effect and can be used as an adjunct in severe hypercalcemia. Used alone, it neither corrects this patient\u0027s volume depletion nor provides durable control, and tachyphylaxis develops within 48\u00E2\u20AC\u201C72 hours."
            },
            {
              "id": "B",
              "text": "Option B: Emergent hemodialysis is inappropriate because hemodialysis is reserved for severe, refractory hypercalcemia or patients who cannot tolerate aggressive hydration due to advanced renal failure or heart failure."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous mannitol is inappropriate because mannitol is not used to treat hypercalcemia and may worsen volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcutaneous calcitonin as sole therapy is inappropriate because calcitonin has a rapid but short-lived calcium-lowering effect and can be used as an adjunct in severe hypercalcemia. Used alone, it neither corrects this patient\u0027s volume depletion nor provides durable control, and tachyphylaxis develops within 48\u00E2\u20AC\u201C72 hours."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plasmapheresis to remove the monoclonal protein is inappropriate because plasmapheresis is used for selected monoclonal-protein complications such as symptomatic hyperviscosity, not as initial therapy for dehydration and symptomatic hypercalcemia. The M spike itself is not an indication for plasma exchange."
            },
            {
              "id": "B",
              "text": "Option B: Emergent hemodialysis is inappropriate because hemodialysis is reserved for severe, refractory hypercalcemia or patients who cannot tolerate aggressive hydration due to advanced renal failure or heart failure."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous mannitol is inappropriate because mannitol is not used to treat hypercalcemia and may worsen volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plasmapheresis to remove the monoclonal protein is inappropriate because plasmapheresis is used for selected monoclonal-protein complications such as symptomatic hyperviscosity, not as initial therapy for dehydration and symptomatic hypercalcemia. The M spike itself is not an indication for plasma exchange."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cinacalcet therapy to suppress parathyroid hormone secretion is inappropriate because cinacalcet is a calcimimetic used for PTH-mediated hypercalcemia, including selected cases of parathyroid carcinoma. The displayed monoclonal protein and free light chains identify malignancy-associated osteolytic hypercalcemia rather than autonomous PTH secretion."
            },
            {
              "id": "B",
              "text": "Option B: Emergent hemodialysis is inappropriate because hemodialysis is reserved for severe, refractory hypercalcemia or patients who cannot tolerate aggressive hydration due to advanced renal failure or heart failure."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous mannitol is inappropriate because mannitol is not used to treat hypercalcemia and may worsen volume depletion."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cinacalcet therapy to suppress parathyroid hormone secretion is inappropriate because cinacalcet is a calcimimetic used for PTH-mediated hypercalcemia, including selected cases of parathyroid carcinoma. The displayed monoclonal protein and free light chains identify malignancy-associated osteolytic hypercalcemia rather than autonomous PTH secretion."
        }
      }
    },
    {
      "externalId": "step3-hematology-vitamin-b12-deficiency-achlorhydria-2247",
      "expectedHashes": {
        "ranaze_step3_uat": "880af9059010b33d8f6f0433a5cf1e256929d820e729bda2071b27806f6d90ab",
        "ranaze_step3_prd": "880af9059010b33d8f6f0433a5cf1e256929d820e729bda2071b27806f6d90ab"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Inadequate dietary folate intake is inappropriate because folate deficiency causes macrocytic anemia but does not cause posterior column dysfunction or peripheral neurologic abnormalities. Her serum folate concentration is also normal."
            },
            {
              "id": "B",
              "text": "Option C: Chronic occult gastrointestinal blood loss is inappropriate because chronic blood loss generally causes iron-deficiency microcytic anemia rather than macrocytosis with impaired vibration and position sensation."
            },
            {
              "id": "C",
              "text": "Option D: Warm autoimmune hemolysis is inappropriate because hemolysis may cause anemia and reticulocytosis but does not typically cause macrocytosis with progressive sensory and gait abnormalities in this pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Inadequate dietary folate intake is inappropriate because folate deficiency causes macrocytic anemia but does not cause posterior column dysfunction or peripheral neurologic abnormalities. Her serum folate concentration is also normal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic occult gastrointestinal blood loss is inappropriate because chronic blood loss generally causes iron-deficiency microcytic anemia rather than macrocytosis with impaired vibration and position sensation."
            },
            {
              "id": "B",
              "text": "Option B: Inadequate dietary folate intake is inappropriate because folate deficiency causes macrocytic anemia but does not cause posterior column dysfunction or peripheral neurologic abnormalities. Her serum folate concentration is also normal."
            },
            {
              "id": "C",
              "text": "Option D: Warm autoimmune hemolysis is inappropriate because hemolysis may cause anemia and reticulocytosis but does not typically cause macrocytosis with progressive sensory and gait abnormalities in this pattern."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic occult gastrointestinal blood loss is inappropriate because chronic blood loss generally causes iron-deficiency microcytic anemia rather than macrocytosis with impaired vibration and position sensation."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Warm autoimmune hemolysis is inappropriate because hemolysis may cause anemia and reticulocytosis but does not typically cause macrocytosis with progressive sensory and gait abnormalities in this pattern."
            },
            {
              "id": "B",
              "text": "Option B: Inadequate dietary folate intake is inappropriate because folate deficiency causes macrocytic anemia but does not cause posterior column dysfunction or peripheral neurologic abnormalities. Her serum folate concentration is also normal."
            },
            {
              "id": "C",
              "text": "Option C: Chronic occult gastrointestinal blood loss is inappropriate because chronic blood loss generally causes iron-deficiency microcytic anemia rather than macrocytosis with impaired vibration and position sensation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Warm autoimmune hemolysis is inappropriate because hemolysis may cause anemia and reticulocytosis but does not typically cause macrocytosis with progressive sensory and gait abnormalities in this pattern."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bone marrow suppression from an herbal supplement is inappropriate because no herbal supplement exposure is described, and medication-related marrow suppression would not specifically explain posterior column findings."
            },
            {
              "id": "B",
              "text": "Option B: Inadequate dietary folate intake is inappropriate because folate deficiency causes macrocytic anemia but does not cause posterior column dysfunction or peripheral neurologic abnormalities. Her serum folate concentration is also normal."
            },
            {
              "id": "C",
              "text": "Option C: Chronic occult gastrointestinal blood loss is inappropriate because chronic blood loss generally causes iron-deficiency microcytic anemia rather than macrocytosis with impaired vibration and position sensation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bone marrow suppression from an herbal supplement is inappropriate because no herbal supplement exposure is described, and medication-related marrow suppression would not specifically explain posterior column findings."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Myelodysplastic syndrome causing ineffective hematopoiesis is inappropriate because myelodysplastic syndrome can cause macrocytic anemia in an older adult, but it does not explain the characteristic loss of vibration and position sensation with gait instability; her normal leukocyte and platelet counts also do not suggest multilineage marrow failure."
            },
            {
              "id": "B",
              "text": "Option B: Inadequate dietary folate intake is inappropriate because folate deficiency causes macrocytic anemia but does not cause posterior column dysfunction or peripheral neurologic abnormalities. Her serum folate concentration is also normal."
            },
            {
              "id": "C",
              "text": "Option C: Chronic occult gastrointestinal blood loss is inappropriate because chronic blood loss generally causes iron-deficiency microcytic anemia rather than macrocytosis with impaired vibration and position sensation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Myelodysplastic syndrome causing ineffective hematopoiesis is inappropriate because myelodysplastic syndrome can cause macrocytic anemia in an older adult, but it does not explain the characteristic loss of vibration and position sensation with gait instability; her normal leukocyte and platelet counts also do not suggest multilineage marrow failure."
        }
      }
    },
    {
      "externalId": "step3-image-ecg-001",
      "expectedHashes": {
        "ranaze_step3_uat": "a62820f0351f4e36a2cdc60feaacccde1040b8e360ae984334a515c487554031"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate synchronized cardioversion is inappropriate because synchronized cardioversion is for unstable tachycardia; this patient is normotensive and alert."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous atropine is inappropriate because atropine treats symptomatic bradycardia, not narrow-complex tachycardia."
            },
            {
              "id": "C",
              "text": "Option D: Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate synchronized cardioversion is inappropriate because synchronized cardioversion is for unstable tachycardia; this patient is normotensive and alert."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous atropine is inappropriate because atropine treats symptomatic bradycardia, not narrow-complex tachycardia."
            },
            {
              "id": "B",
              "text": "Option B: Immediate synchronized cardioversion is inappropriate because synchronized cardioversion is for unstable tachycardia; this patient is normotensive and alert."
            },
            {
              "id": "C",
              "text": "Option D: Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous atropine is inappropriate because atropine treats symptomatic bradycardia, not narrow-complex tachycardia."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation."
            },
            {
              "id": "B",
              "text": "Option B: Immediate synchronized cardioversion is inappropriate because synchronized cardioversion is for unstable tachycardia; this patient is normotensive and alert."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous atropine is inappropriate because atropine treats symptomatic bradycardia, not narrow-complex tachycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral metoprolol and discharge home is inappropriate because discharge without acute rhythm management is inappropriate for ongoing symptomatic tachycardia."
            },
            {
              "id": "B",
              "text": "Option B: Immediate synchronized cardioversion is inappropriate because synchronized cardioversion is for unstable tachycardia; this patient is normotensive and alert."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous atropine is inappropriate because atropine treats symptomatic bradycardia, not narrow-complex tachycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral metoprolol and discharge home is inappropriate because discharge without acute rhythm management is inappropriate for ongoing symptomatic tachycardia."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous amiodarone infusion is inappropriate because amiodarone infusion is an option for stable wide-complex tachycardia, not the initial treatment of this stable regular narrow-complex supraventricular tachycardia. Vagal maneuvers followed by rapid-push adenosine should be attempted first."
            },
            {
              "id": "B",
              "text": "Option B: Immediate synchronized cardioversion is inappropriate because synchronized cardioversion is for unstable tachycardia; this patient is normotensive and alert."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous atropine is inappropriate because atropine treats symptomatic bradycardia, not narrow-complex tachycardia."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous amiodarone infusion is inappropriate because amiodarone infusion is an option for stable wide-complex tachycardia, not the initial treatment of this stable regular narrow-complex supraventricular tachycardia. Vagal maneuvers followed by rapid-push adenosine should be attempted first."
        }
      }
    },
    {
      "externalId": "step3-infectious-bacterial-meningitis-3001",
      "expectedHashes": {
        "ranaze_step3_uat": "b0963143a828fdf4ba245dc59d123400a4a1cf4469efa9b788cb34a49bc21b88"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "B",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            },
            {
              "id": "C",
              "text": "Option D: Vancomycin alone is inappropriate because vancomycin should not be used alone for initial pneumococcal meningitis therapy when susceptibility results are not yet available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option D: Vancomycin alone is inappropriate because vancomycin should not be used alone for initial pneumococcal meningitis therapy when susceptibility results are not yet available."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vancomycin alone is inappropriate because vancomycin should not be used alone for initial pneumococcal meningitis therapy when susceptibility results are not yet available."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vancomycin alone is inappropriate because vancomycin should not be used alone for initial pneumococcal meningitis therapy when susceptibility results are not yet available."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ampicillin plus cefepime is inappropriate because ampicillin is added for Listeria risk, but cefepime is not the preferred companion drug for this otherwise healthy adult with community-acquired pneumococcal meningitis."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ampicillin plus cefepime is inappropriate because ampicillin is added for Listeria risk, but cefepime is not the preferred companion drug for this otherwise healthy adult with community-acquired pneumococcal meningitis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ceftriaxone alone is inappropriate because ceftriaxone monotherapy prematurely omits vancomycin. In suspected pneumococcal meningitis, reduced cephalosporin susceptibility must be covered until susceptibility results permit narrowing."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ceftriaxone alone is inappropriate because ceftriaxone monotherapy prematurely omits vancomycin. In suspected pneumococcal meningitis, reduced cephalosporin susceptibility must be covered until susceptibility results permit narrowing."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Penicillin G alone is inappropriate because penicillin G is appropriate only after the pneumococcal isolate is shown to be penicillin susceptible. Using it alone while susceptibility is pending risks ineffective therapy."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Penicillin G alone is inappropriate because penicillin G is appropriate only after the pneumococcal isolate is shown to be penicillin susceptible. Using it alone while susceptibility is pending risks ineffective therapy."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Piperacillin-tazobactam plus vancomycin is inappropriate because piperacillin-tazobactam is not a recommended pneumococcal meningitis beta-lactam and does not replace a third-generation cephalosporin with established CNS efficacy. This broad sepsis regimen is inappropriate for the identified syndrome."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Piperacillin-tazobactam plus vancomycin is inappropriate because piperacillin-tazobactam is not a recommended pneumococcal meningitis beta-lactam and does not replace a third-generation cephalosporin with established CNS efficacy. This broad sepsis regimen is inappropriate for the identified syndrome."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ceftriaxone plus azithromycin is inappropriate because azithromycin is used for atypical respiratory pathogens, not pneumococcal meningitis. The preceding respiratory illness does not override the diagnostic CSF Gram stain, and this combination omits resistant-pneumococcus coverage with vancomycin."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ceftriaxone plus azithromycin is inappropriate because azithromycin is used for atypical respiratory pathogens, not pneumococcal meningitis. The preceding respiratory illness does not override the diagnostic CSF Gram stain, and this combination omits resistant-pneumococcus coverage with vancomycin."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ceftriaxone plus metronidazole is inappropriate because metronidazole is useful for anaerobic intracranial infections such as selected brain abscesses, not uncomplicated pneumococcal meningitis. This regimen also lacks vancomycin while pneumococcal susceptibility is unknown."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ceftriaxone plus metronidazole is inappropriate because metronidazole is useful for anaerobic intracranial infections such as selected brain abscesses, not uncomplicated pneumococcal meningitis. This regimen also lacks vancomycin while pneumococcal susceptibility is unknown."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ceftriaxone plus vancomycin plus ampicillin is inappropriate because ceftriaxone plus vancomycin supplies the indicated pneumococcal coverage. Adding ampicillin for Listeria is unnecessary in this 46-year-old without immunodeficiency when the Gram stain already shows pneumococcal morphology."
            },
            {
              "id": "B",
              "text": "Option B: Ampicillin plus gentamicin provides Listeria coverage but is not the appropriate regimen for pneumococcal meningitis identified on Gram stain."
            },
            {
              "id": "C",
              "text": "Option C: Ceftazidime plus tobramycin is inappropriate because ceftazidime-based antipseudomonal therapy is used primarily for healthcare-associated meningitis or selected patients with neurosurgical risk factors."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ceftriaxone plus vancomycin plus ampicillin is inappropriate because ceftriaxone plus vancomycin supplies the indicated pneumococcal coverage. Adding ampicillin for Listeria is unnecessary in this 46-year-old without immunodeficiency when the Gram stain already shows pneumococcal morphology."
        }
      }
    },
    {
      "externalId": "step3-infectious-disease-antibiotic-stewardship-viral-uri-962",
      "expectedHashes": {
        "ranaze_step3_uat": "48abb1cbaf2f05ea992b3083cb32e4242a6a2257aec53a982844aaf37b799d0a",
        "ranaze_step3_prd": "48abb1cbaf2f05ea992b3083cb32e4242a6a2257aec53a982844aaf37b799d0a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
            },
            {
              "id": "B",
              "text": "Option C: Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
            },
            {
              "id": "C",
              "text": "Option D: Whether the prescribed medication would be inexpensive is inappropriate because cost matters when selecting among clinically appropriate treatments, not when deciding whether an ineffective treatment should be used."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
            },
            {
              "id": "B",
              "text": "Option B: Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
            },
            {
              "id": "C",
              "text": "Option D: Whether the prescribed medication would be inexpensive is inappropriate because cost matters when selecting among clinically appropriate treatments, not when deciding whether an ineffective treatment should be used."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether the prescribed medication would be inexpensive is inappropriate because cost matters when selecting among clinically appropriate treatments, not when deciding whether an ineffective treatment should be used."
            },
            {
              "id": "B",
              "text": "Option B: Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
            },
            {
              "id": "C",
              "text": "Option C: Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether the prescribed medication would be inexpensive is inappropriate because cost matters when selecting among clinically appropriate treatments, not when deciding whether an ineffective treatment should be used."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether prescribing could contribute to antimicrobial resistance is inappropriate because antimicrobial resistance is an important consequence of unnecessary prescribing, but the initial clinical determination is whether the patient has a bacterial illness that benefits from antibiotics."
            },
            {
              "id": "B",
              "text": "Option B: Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
            },
            {
              "id": "C",
              "text": "Option C: Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether prescribing could contribute to antimicrobial resistance is inappropriate because antimicrobial resistance is an important consequence of unnecessary prescribing, but the initial clinical determination is whether the patient has a bacterial illness that benefits from antibiotics."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether her temperature reaches the conventional definition of fever is inappropriate because a low-grade fever can accompany viral respiratory infections and does not independently establish a bacterial indication. The complete syndrome\u00E2\u20AC\u201Dcongestion, cough, myalgias, sick contact, and absence of focal bacterial findings\u00E2\u20AC\u201Dmust guide the etiologic determination."
            },
            {
              "id": "B",
              "text": "Option B: Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
            },
            {
              "id": "C",
              "text": "Option C: Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether her temperature reaches the conventional definition of fever is inappropriate because a low-grade fever can accompany viral respiratory infections and does not independently establish a bacterial indication. The complete syndrome\u00E2\u20AC\u201Dcongestion, cough, myalgias, sick contact, and absence of focal bacterial findings\u00E2\u20AC\u201Dmust guide the etiologic determination."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether her roommate had the same illness is inappropriate because a roommate with the same self-limited syndrome supports contagious viral infection, but the general prescribing determination remains whether the patient has a bacterial illness that benefits from antibiotics. Contact history alone neither mandates nor selects antibiotic therapy."
            },
            {
              "id": "B",
              "text": "Option B: Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
            },
            {
              "id": "C",
              "text": "Option C: Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether her roommate had the same illness is inappropriate because a roommate with the same self-limited syndrome supports contagious viral infection, but the general prescribing determination remains whether the patient has a bacterial illness that benefits from antibiotics. Contact history alone neither mandates nor selects antibiotic therapy."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether influenza testing is positive is inappropriate because a positive influenza test could affect antiviral decisions, but influenza is viral and is not treated with antibiotics. In a healthy outpatient after 4 days of mild illness, exact viral identification does not create an antibacterial indication."
            },
            {
              "id": "B",
              "text": "Option B: Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
            },
            {
              "id": "C",
              "text": "Option C: Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether influenza testing is positive is inappropriate because a positive influenza test could affect antiviral decisions, but influenza is viral and is not treated with antibiotics. In a healthy outpatient after 4 days of mild illness, exact viral identification does not create an antibacterial indication."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whether antibiotics might prevent a secondary bacterial infection is inappropriate because antibiotics should not be given prophylactically to prevent an unspecified secondary infection during an uncomplicated viral URI. They do not treat the current virus and expose the patient to adverse effects and resistance."
            },
            {
              "id": "B",
              "text": "Option B: Whether the patient is concerned about missing an examination is inappropriate because patient expectations and scheduling concerns should be acknowledged but do not justify treatment unlikely to provide benefit."
            },
            {
              "id": "C",
              "text": "Option C: Whether she might have an unrecognized antibiotic allergy is inappropriate because allergy history becomes relevant when selecting an antibiotic after a bacterial indication has been established."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whether antibiotics might prevent a secondary bacterial infection is inappropriate because antibiotics should not be given prophylactically to prevent an unspecified secondary infection during an uncomplicated viral URI. They do not treat the current virus and expose the patient to adverse effects and resistance."
        }
      }
    },
    {
      "externalId": "step3-labs-dka-001",
      "expectedHashes": {
        "ranaze_step3_uat": "d81fb8650c52184229d9de20c24e7db93d6af5a3a097c4eb8bb9ce6ae1f31607",
        "ranaze_step3_prd": "d81fb8650c52184229d9de20c24e7db93d6af5a3a097c4eb8bb9ce6ae1f31607"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Subcutaneous rapid-acting insulin and discharge home is inappropriate because outpatient subcutaneous insulin is inappropriate for DKA with dehydration and acidosis."
            },
            {
              "id": "B",
              "text": "Option C: Intravenous sodium bicarbonate as the first intervention is inappropriate because bicarbonate is not first-line unless acidemia is severe, typically pH less than 6.9."
            },
            {
              "id": "C",
              "text": "Option D: Fluid restriction and desmopressin treat diabetes insipidus, not DKA."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Subcutaneous rapid-acting insulin and discharge home is inappropriate because outpatient subcutaneous insulin is inappropriate for DKA with dehydration and acidosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intravenous sodium bicarbonate as the first intervention is inappropriate because bicarbonate is not first-line unless acidemia is severe, typically pH less than 6.9."
            },
            {
              "id": "B",
              "text": "Option B: Subcutaneous rapid-acting insulin and discharge home is inappropriate because outpatient subcutaneous insulin is inappropriate for DKA with dehydration and acidosis."
            },
            {
              "id": "C",
              "text": "Option D: Fluid restriction and desmopressin treat diabetes insipidus, not DKA."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intravenous sodium bicarbonate as the first intervention is inappropriate because bicarbonate is not first-line unless acidemia is severe, typically pH less than 6.9."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fluid restriction and desmopressin treat diabetes insipidus, not DKA."
            },
            {
              "id": "B",
              "text": "Option B: Subcutaneous rapid-acting insulin and discharge home is inappropriate because outpatient subcutaneous insulin is inappropriate for DKA with dehydration and acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous sodium bicarbonate as the first intervention is inappropriate because bicarbonate is not first-line unless acidemia is severe, typically pH less than 6.9."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fluid restriction and desmopressin treat diabetes insipidus, not DKA."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Oral potassium supplementation only is inappropriate because potassium management is important, but potassium alone does not treat DKA."
            },
            {
              "id": "B",
              "text": "Option B: Subcutaneous rapid-acting insulin and discharge home is inappropriate because outpatient subcutaneous insulin is inappropriate for DKA with dehydration and acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous sodium bicarbonate as the first intervention is inappropriate because bicarbonate is not first-line unless acidemia is severe, typically pH less than 6.9."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Oral potassium supplementation only is inappropriate because potassium management is important, but potassium alone does not treat DKA."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin an intravenous regular insulin infusion immediately and defer fluids until the glucose decreases is inappropriate because dKA causes substantial volume depletion. Isotonic fluid resuscitation should begin promptly; deferring fluids while starting insulin can worsen intravascular depletion and impair perfusion."
            },
            {
              "id": "B",
              "text": "Option B: Subcutaneous rapid-acting insulin and discharge home is inappropriate because outpatient subcutaneous insulin is inappropriate for DKA with dehydration and acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous sodium bicarbonate as the first intervention is inappropriate because bicarbonate is not first-line unless acidemia is severe, typically pH less than 6.9."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin an intravenous regular insulin infusion immediately and defer fluids until the glucose decreases is inappropriate because dKA causes substantial volume depletion. Isotonic fluid resuscitation should begin promptly; deferring fluids while starting insulin can worsen intravascular depletion and impair perfusion."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin 5% dextrose in 0.45% saline as the initial intravenous fluid is inappropriate because dextrose is added after plasma glucose falls below approximately 250 mg/dL so insulin can continue while ketoacidosis resolves. With an initial glucose of 486 mg/dL, resuscitation should begin with an isotonic crystalloid without dextrose."
            },
            {
              "id": "B",
              "text": "Option B: Subcutaneous rapid-acting insulin and discharge home is inappropriate because outpatient subcutaneous insulin is inappropriate for DKA with dehydration and acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous sodium bicarbonate as the first intervention is inappropriate because bicarbonate is not first-line unless acidemia is severe, typically pH less than 6.9."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin 5% dextrose in 0.45% saline as the initial intravenous fluid is inappropriate because dextrose is added after plasma glucose falls below approximately 250 mg/dL so insulin can continue while ketoacidosis resolves. With an initial glucose of 486 mg/dL, resuscitation should begin with an isotonic crystalloid without dextrose."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Withhold insulin and give intravenous potassium until the serum potassium exceeds 5.0 mEq/L is inappropriate because insulin is delayed for hypokalemia below 3.5 mEq/L, not for a potassium of 4.8 mEq/L. Potassium must be monitored and typically added as its concentration falls, but raising it above 5.0 before insulin would unnecessarily delay definitive therapy."
            },
            {
              "id": "B",
              "text": "Option B: Subcutaneous rapid-acting insulin and discharge home is inappropriate because outpatient subcutaneous insulin is inappropriate for DKA with dehydration and acidosis."
            },
            {
              "id": "C",
              "text": "Option C: Intravenous sodium bicarbonate as the first intervention is inappropriate because bicarbonate is not first-line unless acidemia is severe, typically pH less than 6.9."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Withhold insulin and give intravenous potassium until the serum potassium exceeds 5.0 mEq/L is inappropriate because insulin is delayed for hypokalemia below 3.5 mEq/L, not for a potassium of 4.8 mEq/L. Potassium must be monitored and typically added as its concentration falls, but raising it above 5.0 before insulin would unnecessarily delay definitive therapy."
        }
      }
    },
    {
      "externalId": "step3-musculoskeletal-hip-fracture-position-962",
      "expectedHashes": {
        "ranaze_step3_uat": "4380e6eee7fc1df07d8019176417b1e421ebfc0ef960a9061fab6d8c015bbeaf",
        "ranaze_step3_prd": "4380e6eee7fc1df07d8019176417b1e421ebfc0ef960a9061fab6d8c015bbeaf"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Flexion and internal rotation of the right hip is inappropriate because flexion and internal rotation are more characteristic of a posterior hip dislocation rather than a typical hip fracture after a low-energy fall."
            },
            {
              "id": "B",
              "text": "Option C: Extension and abduction of the right hip is inappropriate because extension and abduction are not the expected resting position after a proximal femoral fracture."
            },
            {
              "id": "C",
              "text": "Option D: Isolated external rotation without shortening is inappropriate because external rotation may occur, but shortening is also typically present when the fracture is displaced."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Flexion and internal rotation of the right hip is inappropriate because flexion and internal rotation are more characteristic of a posterior hip dislocation rather than a typical hip fracture after a low-energy fall."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Extension and abduction of the right hip is inappropriate because extension and abduction are not the expected resting position after a proximal femoral fracture."
            },
            {
              "id": "B",
              "text": "Option B: Flexion and internal rotation of the right hip is inappropriate because flexion and internal rotation are more characteristic of a posterior hip dislocation rather than a typical hip fracture after a low-energy fall."
            },
            {
              "id": "C",
              "text": "Option D: Isolated external rotation without shortening is inappropriate because external rotation may occur, but shortening is also typically present when the fracture is displaced."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Extension and abduction of the right hip is inappropriate because extension and abduction are not the expected resting position after a proximal femoral fracture."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isolated external rotation without shortening is inappropriate because external rotation may occur, but shortening is also typically present when the fracture is displaced."
            },
            {
              "id": "B",
              "text": "Option B: Flexion and internal rotation of the right hip is inappropriate because flexion and internal rotation are more characteristic of a posterior hip dislocation rather than a typical hip fracture after a low-energy fall."
            },
            {
              "id": "C",
              "text": "Option C: Extension and abduction of the right hip is inappropriate because extension and abduction are not the expected resting position after a proximal femoral fracture."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isolated external rotation without shortening is inappropriate because external rotation may occur, but shortening is also typically present when the fracture is displaced."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hyperextension of the right knee is inappropriate because knee hyperextension is not a characteristic finding of hip fracture."
            },
            {
              "id": "B",
              "text": "Option B: Flexion and internal rotation of the right hip is inappropriate because flexion and internal rotation are more characteristic of a posterior hip dislocation rather than a typical hip fracture after a low-energy fall."
            },
            {
              "id": "C",
              "text": "Option C: Extension and abduction of the right hip is inappropriate because extension and abduction are not the expected resting position after a proximal femoral fracture."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hyperextension of the right knee is inappropriate because knee hyperextension is not a characteristic finding of hip fracture."
        }
      }
    },
    {
      "externalId": "step3-musculoskeletal-lateral-epicondylitis-clinical-diagnosis-1227",
      "expectedHashes": {
        "ranaze_step3_uat": "0fa0be4c472537f84e910eae83d2410128948210634427ee4f0ae12b6ae55338",
        "ranaze_step3_prd": "0fa0be4c472537f84e910eae83d2410128948210634427ee4f0ae12b6ae55338"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plain radiographs of the elbow is inappropriate because radiographs are appropriate when fracture, arthritis, osteochondral injury, or significant trauma is suspected, none of which is present here."
            },
            {
              "id": "B",
              "text": "Option C: MRI of the elbow is inappropriate because mRI is reserved for atypical symptoms, suspected tendon rupture, or persistent symptoms despite appropriate conservative treatment."
            },
            {
              "id": "C",
              "text": "Option D: Arthrocentesis with synovial fluid analysis is inappropriate because arthrocentesis is indicated when septic arthritis or crystal arthritis is suspected; this patient has no effusion, warmth, erythema, or systemic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plain radiographs of the elbow is inappropriate because radiographs are appropriate when fracture, arthritis, osteochondral injury, or significant trauma is suspected, none of which is present here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the elbow is inappropriate because mRI is reserved for atypical symptoms, suspected tendon rupture, or persistent symptoms despite appropriate conservative treatment."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the elbow is inappropriate because radiographs are appropriate when fracture, arthritis, osteochondral injury, or significant trauma is suspected, none of which is present here."
            },
            {
              "id": "C",
              "text": "Option D: Arthrocentesis with synovial fluid analysis is inappropriate because arthrocentesis is indicated when septic arthritis or crystal arthritis is suspected; this patient has no effusion, warmth, erythema, or systemic symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the elbow is inappropriate because mRI is reserved for atypical symptoms, suspected tendon rupture, or persistent symptoms despite appropriate conservative treatment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Arthrocentesis with synovial fluid analysis is inappropriate because arthrocentesis is indicated when septic arthritis or crystal arthritis is suspected; this patient has no effusion, warmth, erythema, or systemic symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the elbow is inappropriate because radiographs are appropriate when fracture, arthritis, osteochondral injury, or significant trauma is suspected, none of which is present here."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the elbow is inappropriate because mRI is reserved for atypical symptoms, suspected tendon rupture, or persistent symptoms despite appropriate conservative treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Arthrocentesis with synovial fluid analysis is inappropriate because arthrocentesis is indicated when septic arthritis or crystal arthritis is suspected; this patient has no effusion, warmth, erythema, or systemic symptoms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diagnostic elbow arthroscopy is inappropriate because arthroscopy is invasive and is not part of the initial evaluation of uncomplicated lateral epicondylitis."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the elbow is inappropriate because radiographs are appropriate when fracture, arthritis, osteochondral injury, or significant trauma is suspected, none of which is present here."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the elbow is inappropriate because mRI is reserved for atypical symptoms, suspected tendon rupture, or persistent symptoms despite appropriate conservative treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diagnostic elbow arthroscopy is inappropriate because arthroscopy is invasive and is not part of the initial evaluation of uncomplicated lateral epicondylitis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is used when nerve compression or neuropathy is suspected. This patient\u0027s activity-related focal tendon pain and characteristic provocative examination do not suggest radial, ulnar, or cervical nerve dysfunction."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the elbow is inappropriate because radiographs are appropriate when fracture, arthritis, osteochondral injury, or significant trauma is suspected, none of which is present here."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the elbow is inappropriate because mRI is reserved for atypical symptoms, suspected tendon rupture, or persistent symptoms despite appropriate conservative treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electromyography and nerve conduction studies is inappropriate because electrodiagnostic testing is used when nerve compression or neuropathy is suspected. This patient\u0027s activity-related focal tendon pain and characteristic provocative examination do not suggest radial, ulnar, or cervical nerve dysfunction."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the cervical spine is inappropriate because cervical spine MRI may be useful when cervical radiculopathy is suspected, but the precisely localized elbow tenderness and reproduction of pain by resisted wrist extension identify a local extensor-tendon disorder."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the elbow is inappropriate because radiographs are appropriate when fracture, arthritis, osteochondral injury, or significant trauma is suspected, none of which is present here."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the elbow is inappropriate because mRI is reserved for atypical symptoms, suspected tendon rupture, or persistent symptoms despite appropriate conservative treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the cervical spine is inappropriate because cervical spine MRI may be useful when cervical radiculopathy is suspected, but the precisely localized elbow tenderness and reproduction of pain by resisted wrist extension identify a local extensor-tendon disorder."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Erythrocyte sedimentation rate and C-reactive protein measurement is inappropriate because inflammatory markers may help evaluate systemic inflammatory or infectious disease. The absence of fever, morning stiffness, other involved joints, effusion, erythema, and warmth makes such testing unnecessary."
            },
            {
              "id": "B",
              "text": "Option B: Plain radiographs of the elbow is inappropriate because radiographs are appropriate when fracture, arthritis, osteochondral injury, or significant trauma is suspected, none of which is present here."
            },
            {
              "id": "C",
              "text": "Option C: MRI of the elbow is inappropriate because mRI is reserved for atypical symptoms, suspected tendon rupture, or persistent symptoms despite appropriate conservative treatment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Erythrocyte sedimentation rate and C-reactive protein measurement is inappropriate because inflammatory markers may help evaluate systemic inflammatory or infectious disease. The absence of fever, morning stiffness, other involved joints, effusion, erythema, and warmth makes such testing unnecessary."
        }
      }
    },
    {
      "externalId": "step3-musculoskeletal-scoliosis-screen-422",
      "expectedHashes": {
        "ranaze_step3_uat": "301714b5a59fae6f96bebc6142a330a1cfee6b82fb65b1ce54e5b9db109d6c06",
        "ranaze_step3_prd": "301714b5a59fae6f96bebc6142a330a1cfee6b82fb65b1ce54e5b9db109d6c06"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "B",
              "text": "Option C: Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            },
            {
              "id": "C",
              "text": "Option D: Palpate the paraspinal muscles for tenderness and spasm is inappropriate because paraspinal tenderness may support muscular strain but does not evaluate spinal rotation or lateral curvature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            },
            {
              "id": "B",
              "text": "Option B: Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "C",
              "text": "Option D: Palpate the paraspinal muscles for tenderness and spasm is inappropriate because paraspinal tenderness may support muscular strain but does not evaluate spinal rotation or lateral curvature."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Palpate the paraspinal muscles for tenderness and spasm is inappropriate because paraspinal tenderness may support muscular strain but does not evaluate spinal rotation or lateral curvature."
            },
            {
              "id": "B",
              "text": "Option B: Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Palpate the paraspinal muscles for tenderness and spasm is inappropriate because paraspinal tenderness may support muscular strain but does not evaluate spinal rotation or lateral curvature."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform straight-leg raise testing bilaterally is inappropriate because straight-leg raise testing evaluates lumbosacral nerve-root irritation and is not a scoliosis assessment maneuver."
            },
            {
              "id": "B",
              "text": "Option B: Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform straight-leg raise testing bilaterally is inappropriate because straight-leg raise testing evaluates lumbosacral nerve-root irritation and is not a scoliosis assessment maneuver."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Assess coronal balance by dropping a plumb line from C7 to the gluteal cleft is inappropriate because a plumb line assesses global coronal alignment but may miss the rotational rib or lumbar prominence of early adolescent idiopathic scoliosis. The Adams forward bend test with scoliometer measurement is the more appropriate initial targeted maneuver."
            },
            {
              "id": "B",
              "text": "Option B: Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Assess coronal balance by dropping a plumb line from C7 to the gluteal cleft is inappropriate because a plumb line assesses global coronal alignment but may miss the rotational rib or lumbar prominence of early adolescent idiopathic scoliosis. The Adams forward bend test with scoliometer measurement is the more appropriate initial targeted maneuver."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform lateral-bending maneuvers to determine whether the suspected spinal curve is flexible is inappropriate because lateral-bending views or maneuvers help characterize the flexibility of an already recognized curve; they are not the initial screening maneuver when no curve or asymmetry has yet been identified."
            },
            {
              "id": "B",
              "text": "Option B: Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform lateral-bending maneuvers to determine whether the suspected spinal curve is flexible is inappropriate because lateral-bending views or maneuvers help characterize the flexibility of an already recognized curve; they are not the initial screening maneuver when no curve or asymmetry has yet been identified."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure lumbar flexion with the modified Schober test is inappropriate because the modified Schober test measures lumbar flexion and is used when restricted mobility from inflammatory spinal disease is suspected. Her brief exertional soreness without persistent or nocturnal pain does not suggest that problem, and the test does not assess scoliosis-related trunk rotation."
            },
            {
              "id": "B",
              "text": "Option B: Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure lumbar flexion with the modified Schober test is inappropriate because the modified Schober test measures lumbar flexion and is used when restricted mobility from inflammatory spinal disease is suspected. Her brief exertional soreness without persistent or nocturnal pain does not suggest that problem, and the test does not assess scoliosis-related trunk rotation."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a detailed lower-extremity neurologic examination as the primary screening maneuver is inappropriate because a neurologic examination is important when scoliosis is atypical or neurologic symptoms are present, but it does not replace the forward bend test as the primary maneuver for detecting scoliosis. This patient denies weakness, numbness, and bowel or bladder symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a detailed lower-extremity neurologic examination as the primary screening maneuver is inappropriate because a neurologic examination is important when scoliosis is atypical or neurologic symptoms are present, but it does not replace the forward bend test as the primary maneuver for detecting scoliosis. This patient denies weakness, numbness, and bowel or bladder symptoms."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform a single-leg hyperextension test to evaluate for spondylolysis is inappropriate because the single-leg hyperextension or stork test is intended to provoke pain from a posterior-element stress injury, not detect vertebral rotation. Occasional soreness after prolonged tournaments that resolves with rest does not make this the primary scoliosis maneuver."
            },
            {
              "id": "B",
              "text": "Option B: Measure leg lengths from the anterior superior iliac spine to the medial malleolus is inappropriate because leg-length assessment can identify pelvic obliquity and a functional curve but is not the primary test for the rotational deformity of adolescent idiopathic scoliosis."
            },
            {
              "id": "C",
              "text": "Option C: Obtain standing posteroanterior and lateral radiographs of the thoracolumbar spine is inappropriate because radiographs confirm scoliosis and quantify the Cobb angle after a concerning examination; immediate radiation exposure is unnecessary before the clinical assessment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform a single-leg hyperextension test to evaluate for spondylolysis is inappropriate because the single-leg hyperextension or stork test is intended to provoke pain from a posterior-element stress injury, not detect vertebral rotation. Occasional soreness after prolonged tournaments that resolves with rest does not make this the primary scoliosis maneuver."
        }
      }
    },
    {
      "externalId": "step3-musculoskeletal-segond-fracture-acl-injury-2974",
      "expectedHashes": {
        "ranaze_step3_uat": "3aa531ae1290a8b32383ee28eb3ed0d4756f6db9fb7433932ea441f20e185766",
        "ranaze_step3_prd": "3aa531ae1290a8b32383ee28eb3ed0d4756f6db9fb7433932ea441f20e185766"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Posterior cruciate ligament injury usually follows a posteriorly directed force on the proximal tibia, such as a dashboard injury, and is assessed with the posterior drawer test."
            },
            {
              "id": "B",
              "text": "Option C: Medial collateral ligament injury usually results from a valgus force and causes focal medial tenderness and valgus laxity."
            },
            {
              "id": "C",
              "text": "Option D: Medial meniscus is inappropriate because a meniscal tear can occur with twisting and may cause locking or joint-line tenderness, but a Segond fracture most strongly indicates ACL rupture."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Posterior cruciate ligament injury usually follows a posteriorly directed force on the proximal tibia, such as a dashboard injury, and is assessed with the posterior drawer test."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Medial collateral ligament injury usually results from a valgus force and causes focal medial tenderness and valgus laxity."
            },
            {
              "id": "B",
              "text": "Option B: Posterior cruciate ligament injury usually follows a posteriorly directed force on the proximal tibia, such as a dashboard injury, and is assessed with the posterior drawer test."
            },
            {
              "id": "C",
              "text": "Option D: Medial meniscus is inappropriate because a meniscal tear can occur with twisting and may cause locking or joint-line tenderness, but a Segond fracture most strongly indicates ACL rupture."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Medial collateral ligament injury usually results from a valgus force and causes focal medial tenderness and valgus laxity."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Medial meniscus is inappropriate because a meniscal tear can occur with twisting and may cause locking or joint-line tenderness, but a Segond fracture most strongly indicates ACL rupture."
            },
            {
              "id": "B",
              "text": "Option B: Posterior cruciate ligament injury usually follows a posteriorly directed force on the proximal tibia, such as a dashboard injury, and is assessed with the posterior drawer test."
            },
            {
              "id": "C",
              "text": "Option C: Medial collateral ligament injury usually results from a valgus force and causes focal medial tenderness and valgus laxity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Medial meniscus is inappropriate because a meniscal tear can occur with twisting and may cause locking or joint-line tenderness, but a Segond fracture most strongly indicates ACL rupture."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Patellar tendon rupture causes loss of active knee extension, which is not present in this patient."
            },
            {
              "id": "B",
              "text": "Option B: Posterior cruciate ligament injury usually follows a posteriorly directed force on the proximal tibia, such as a dashboard injury, and is assessed with the posterior drawer test."
            },
            {
              "id": "C",
              "text": "Option C: Medial collateral ligament injury usually results from a valgus force and causes focal medial tenderness and valgus laxity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Patellar tendon rupture causes loss of active knee extension, which is not present in this patient."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A lateral collateral ligament tear is usually caused by a force applied to the medial knee that produces varus stress and commonly causes focal lateral tenderness or instability. This was a noncontact pivot injury, and the lateral proximal tibial plateau avulsion is a Segond fracture that points much more strongly to ACL rupture."
            },
            {
              "id": "B",
              "text": "Option B: Posterior cruciate ligament injury usually follows a posteriorly directed force on the proximal tibia, such as a dashboard injury, and is assessed with the posterior drawer test."
            },
            {
              "id": "C",
              "text": "Option C: Medial collateral ligament injury usually results from a valgus force and causes focal medial tenderness and valgus laxity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A lateral collateral ligament tear is usually caused by a force applied to the medial knee that produces varus stress and commonly causes focal lateral tenderness or instability. This was a noncontact pivot injury, and the lateral proximal tibial plateau avulsion is a Segond fracture that points much more strongly to ACL rupture."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The medial patellofemoral ligament is commonly damaged when the patella dislocates laterally, and patellar dislocation can follow a noncontact pivot. However, the stem describes no patellar displacement or instability and instead shows an avulsion at the lateral proximal tibial plateau, the classic Segond-fracture location associated with ACL rupture."
            },
            {
              "id": "B",
              "text": "Option B: Posterior cruciate ligament injury usually follows a posteriorly directed force on the proximal tibia, such as a dashboard injury, and is assessed with the posterior drawer test."
            },
            {
              "id": "C",
              "text": "Option C: Medial collateral ligament injury usually results from a valgus force and causes focal medial tenderness and valgus laxity."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The medial patellofemoral ligament is commonly damaged when the patella dislocates laterally, and patellar dislocation can follow a noncontact pivot. However, the stem describes no patellar displacement or instability and instead shows an avulsion at the lateral proximal tibial plateau, the classic Segond-fracture location associated with ACL rupture."
        }
      }
    },
    {
      "externalId": "step3-neuro-brain-death-brainstem-reflexes-3914",
      "expectedHashes": {
        "ranaze_step3_uat": "757806d3aaecb5012f5fd0200b52323a0ffde1c4a2cbac7062be35e53b636646",
        "ranaze_step3_prd": "757806d3aaecb5012f5fd0200b52323a0ffde1c4a2cbac7062be35e53b636646"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Decorticate posturing with painful stimulation is inappropriate because decorticate posturing is a brain-mediated motor response and is incompatible with brain death."
            },
            {
              "id": "B",
              "text": "Option C: Slow conjugate eye deviation toward the irrigated ear during cold caloric testing is inappropriate because eye deviation toward the irrigated ear during cold caloric testing indicates an intact vestibulo-ocular brainstem response and argues against brain death."
            },
            {
              "id": "C",
              "text": "Option D: Spontaneous flexion of the lower extremities is inappropriate because limb flexion may represent a spinal reflex and can occur despite brain death, so it is not independently confirmatory."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Decorticate posturing with painful stimulation is inappropriate because decorticate posturing is a brain-mediated motor response and is incompatible with brain death."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Slow conjugate eye deviation toward the irrigated ear during cold caloric testing is inappropriate because eye deviation toward the irrigated ear during cold caloric testing indicates an intact vestibulo-ocular brainstem response and argues against brain death."
            },
            {
              "id": "B",
              "text": "Option B: Decorticate posturing with painful stimulation is inappropriate because decorticate posturing is a brain-mediated motor response and is incompatible with brain death."
            },
            {
              "id": "C",
              "text": "Option D: Spontaneous flexion of the lower extremities is inappropriate because limb flexion may represent a spinal reflex and can occur despite brain death, so it is not independently confirmatory."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Slow conjugate eye deviation toward the irrigated ear during cold caloric testing is inappropriate because eye deviation toward the irrigated ear during cold caloric testing indicates an intact vestibulo-ocular brainstem response and argues against brain death."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Spontaneous flexion of the lower extremities is inappropriate because limb flexion may represent a spinal reflex and can occur despite brain death, so it is not independently confirmatory."
            },
            {
              "id": "B",
              "text": "Option B: Decorticate posturing with painful stimulation is inappropriate because decorticate posturing is a brain-mediated motor response and is incompatible with brain death."
            },
            {
              "id": "C",
              "text": "Option C: Slow conjugate eye deviation toward the irrigated ear during cold caloric testing is inappropriate because eye deviation toward the irrigated ear during cold caloric testing indicates an intact vestibulo-ocular brainstem response and argues against brain death."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Spontaneous flexion of the lower extremities is inappropriate because limb flexion may represent a spinal reflex and can occur despite brain death, so it is not independently confirmatory."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Preserved gag reflex during suctioning is inappropriate because a preserved gag reflex indicates intact medullary function and excludes brain death."
            },
            {
              "id": "B",
              "text": "Option B: Decorticate posturing with painful stimulation is inappropriate because decorticate posturing is a brain-mediated motor response and is incompatible with brain death."
            },
            {
              "id": "C",
              "text": "Option C: Slow conjugate eye deviation toward the irrigated ear during cold caloric testing is inappropriate because eye deviation toward the irrigated ear during cold caloric testing indicates an intact vestibulo-ocular brainstem response and argues against brain death."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Preserved gag reflex during suctioning is inappropriate because a preserved gag reflex indicates intact medullary function and excludes brain death."
        }
      }
    },
    {
      "externalId": "step3-neurology-idiopathic-intracranial-hypertension-papilledema-1024",
      "expectedHashes": {
        "ranaze_step3_uat": "60e4b6a0b4246cb4f51feb1cf4e943b6aeb1f7f3efa54d3ae40e7d1502bb222c",
        "ranaze_step3_prd": "60e4b6a0b4246cb4f51feb1cf4e943b6aeb1f7f3efa54d3ae40e7d1502bb222c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
            },
            {
              "id": "B",
              "text": "Option C: A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
            },
            {
              "id": "C",
              "text": "Option D: Loss of vibration sensation in both feet is inappropriate because loss of vibration sensation suggests posterior column or peripheral nerve dysfunction, which is unrelated to raised intracranial pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
            },
            {
              "id": "B",
              "text": "Option B: Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
            },
            {
              "id": "C",
              "text": "Option D: Loss of vibration sensation in both feet is inappropriate because loss of vibration sensation suggests posterior column or peripheral nerve dysfunction, which is unrelated to raised intracranial pressure."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Loss of vibration sensation in both feet is inappropriate because loss of vibration sensation suggests posterior column or peripheral nerve dysfunction, which is unrelated to raised intracranial pressure."
            },
            {
              "id": "B",
              "text": "Option B: Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
            },
            {
              "id": "C",
              "text": "Option C: A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Loss of vibration sensation in both feet is inappropriate because loss of vibration sensation suggests posterior column or peripheral nerve dysfunction, which is unrelated to raised intracranial pressure."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Sustained ankle clonus indicates an upper motor neuron lesion and is not expected in otherwise uncomplicated idiopathic intracranial hypertension."
            },
            {
              "id": "B",
              "text": "Option B: Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
            },
            {
              "id": "C",
              "text": "Option C: A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Sustained ankle clonus indicates an upper motor neuron lesion and is not expected in otherwise uncomplicated idiopathic intracranial hypertension."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A unilateral relative afferent pupillary defect with red desaturation is inappropriate because a unilateral relative afferent pupillary defect with color desaturation is typical of asymmetric optic neuropathy such as optic neuritis. Early papilledema from IIH is generally bilateral, and pupillary responses are usually normal unless optic-nerve injury becomes advanced or markedly asymmetric."
            },
            {
              "id": "B",
              "text": "Option B: Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
            },
            {
              "id": "C",
              "text": "Option C: A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A unilateral relative afferent pupillary defect with red desaturation is inappropriate because a unilateral relative afferent pupillary defect with color desaturation is typical of asymmetric optic neuropathy such as optic neuritis. Early papilledema from IIH is generally bilateral, and pupillary responses are usually normal unless optic-nerve injury becomes advanced or markedly asymmetric."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Diffuse flame-shaped retinal hemorrhages and cotton-wool spots is inappropriate because diffuse flame hemorrhages and cotton-wool spots suggest severe hypertensive retinopathy. Her blood pressure is normal, whereas the combination of obesity, weight gain, pressure-type headache, pulsatile tinnitus, and transient visual obscurations is characteristic of IIH."
            },
            {
              "id": "B",
              "text": "Option B: Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
            },
            {
              "id": "C",
              "text": "Option C: A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Diffuse flame-shaped retinal hemorrhages and cotton-wool spots is inappropriate because diffuse flame hemorrhages and cotton-wool spots suggest severe hypertensive retinopathy. Her blood pressure is normal, whereas the combination of obesity, weight gain, pressure-type headache, pulsatile tinnitus, and transient visual obscurations is characteristic of IIH."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bilateral optic disc elevation caused by buried optic nerve drusen is inappropriate because optic nerve drusen can produce pseudopapilledema, but they do not explain the classic raised-intracranial-pressure syndrome of morning and cough-exacerbated headache, pulsatile tinnitus, and transient visual obscurations. True papilledema is therefore more likely."
            },
            {
              "id": "B",
              "text": "Option B: Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
            },
            {
              "id": "C",
              "text": "Option C: A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bilateral optic disc elevation caused by buried optic nerve drusen is inappropriate because optic nerve drusen can produce pseudopapilledema, but they do not explain the classic raised-intracranial-pressure syndrome of morning and cough-exacerbated headache, pulsatile tinnitus, and transient visual obscurations. True papilledema is therefore more likely."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bilateral optic disc cupping with peripheral visual-field loss is inappropriate because optic disc cupping with corresponding visual-field loss is characteristic of glaucomatous optic neuropathy. This patient\u0027s pressure-type headaches, pulsatile tinnitus, and brief binocular visual obscurations instead indicate raised intracranial pressure from idiopathic intracranial hypertension, for which bilateral optic disc swelling with blurred margins is expected."
            },
            {
              "id": "B",
              "text": "Option B: Internuclear ophthalmoplegia suggests a medial longitudinal fasciculus lesion, often due to multiple sclerosis or brainstem ischemia, and does not fit this presentation."
            },
            {
              "id": "C",
              "text": "Option C: A unilateral fixed, dilated pupil suggests third nerve compression, such as from uncal herniation or a posterior communicating artery aneurysm."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bilateral optic disc cupping with peripheral visual-field loss is inappropriate because optic disc cupping with corresponding visual-field loss is characteristic of glaucomatous optic neuropathy. This patient\u0027s pressure-type headaches, pulsatile tinnitus, and brief binocular visual obscurations instead indicate raised intracranial pressure from idiopathic intracranial hypertension, for which bilateral optic disc swelling with blurred margins is expected."
        }
      }
    },
    {
      "externalId": "step3-neurology-transient-ischemic-attack-carotid-ultrasound-1819",
      "expectedHashes": {
        "ranaze_step3_uat": "d2e5cc3ffaa7445ca9ac55e9cf5aebebcdb8504f0553ac6a6bdf16af54cdb2f1",
        "ranaze_step3_prd": "d2e5cc3ffaa7445ca9ac55e9cf5aebebcdb8504f0553ac6a6bdf16af54cdb2f1"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Catheter-based coronary angiography is inappropriate because coronary angiography evaluates the coronary arteries and is not the appropriate study for transient focal neurologic deficits without symptoms of myocardial ischemia."
            },
            {
              "id": "B",
              "text": "Option C: Radionuclide cerebral perfusion scanning is not the preferred initial vascular study for suspected carotid-source transient ischemic attack."
            },
            {
              "id": "C",
              "text": "Option D: Upper-extremity venography evaluates venous thrombosis and does not assess the arterial circulation supplying the brain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Catheter-based coronary angiography is inappropriate because coronary angiography evaluates the coronary arteries and is not the appropriate study for transient focal neurologic deficits without symptoms of myocardial ischemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radionuclide cerebral perfusion scanning is not the preferred initial vascular study for suspected carotid-source transient ischemic attack."
            },
            {
              "id": "B",
              "text": "Option B: Catheter-based coronary angiography is inappropriate because coronary angiography evaluates the coronary arteries and is not the appropriate study for transient focal neurologic deficits without symptoms of myocardial ischemia."
            },
            {
              "id": "C",
              "text": "Option D: Upper-extremity venography evaluates venous thrombosis and does not assess the arterial circulation supplying the brain."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radionuclide cerebral perfusion scanning is not the preferred initial vascular study for suspected carotid-source transient ischemic attack."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Upper-extremity venography evaluates venous thrombosis and does not assess the arterial circulation supplying the brain."
            },
            {
              "id": "B",
              "text": "Option B: Catheter-based coronary angiography is inappropriate because coronary angiography evaluates the coronary arteries and is not the appropriate study for transient focal neurologic deficits without symptoms of myocardial ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide cerebral perfusion scanning is not the preferred initial vascular study for suspected carotid-source transient ischemic attack."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Upper-extremity venography evaluates venous thrombosis and does not assess the arterial circulation supplying the brain."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Plain radiographs of the cervical spine is inappropriate because cervical spine radiographs do not evaluate cerebral ischemia or carotid atherosclerosis."
            },
            {
              "id": "B",
              "text": "Option B: Catheter-based coronary angiography is inappropriate because coronary angiography evaluates the coronary arteries and is not the appropriate study for transient focal neurologic deficits without symptoms of myocardial ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide cerebral perfusion scanning is not the preferred initial vascular study for suspected carotid-source transient ischemic attack."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Plain radiographs of the cervical spine is inappropriate because cervical spine radiographs do not evaluate cerebral ischemia or carotid atherosclerosis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transthoracic echocardiography is inappropriate because echocardiography can identify selected structural cardioembolic sources, but this patient has a regular rhythm, normal ECG, left-hemispheric symptoms, and an ipsilateral carotid bruit. Direct noninvasive assessment of the extracranial carotid arteries is the higher-priority study."
            },
            {
              "id": "B",
              "text": "Option B: Catheter-based coronary angiography is inappropriate because coronary angiography evaluates the coronary arteries and is not the appropriate study for transient focal neurologic deficits without symptoms of myocardial ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide cerebral perfusion scanning is not the preferred initial vascular study for suspected carotid-source transient ischemic attack."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transthoracic echocardiography is inappropriate because echocardiography can identify selected structural cardioembolic sources, but this patient has a regular rhythm, normal ECG, left-hemispheric symptoms, and an ipsilateral carotid bruit. Direct noninvasive assessment of the extracranial carotid arteries is the higher-priority study."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thirty-day ambulatory cardiac rhythm monitoring is inappropriate because prolonged rhythm monitoring is useful when occult atrial fibrillation remains a concern, especially when no other cause is identified. It should not precede evaluation of an immediately suggested symptomatic carotid lesion in this patient."
            },
            {
              "id": "B",
              "text": "Option B: Catheter-based coronary angiography is inappropriate because coronary angiography evaluates the coronary arteries and is not the appropriate study for transient focal neurologic deficits without symptoms of myocardial ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide cerebral perfusion scanning is not the preferred initial vascular study for suspected carotid-source transient ischemic attack."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thirty-day ambulatory cardiac rhythm monitoring is inappropriate because prolonged rhythm monitoring is useful when occult atrial fibrillation remains a concern, especially when no other cause is identified. It should not precede evaluation of an immediately suggested symptomatic carotid lesion in this patient."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transcranial Doppler ultrasonography is inappropriate because transcranial Doppler assesses intracranial arterial flow but is rated inappropriate as the initial imaging test for a resolved clinical TIA. The bruit and hemispheric symptoms specifically implicate the extracranial left carotid circulation, which carotid duplex examines directly."
            },
            {
              "id": "B",
              "text": "Option B: Catheter-based coronary angiography is inappropriate because coronary angiography evaluates the coronary arteries and is not the appropriate study for transient focal neurologic deficits without symptoms of myocardial ischemia."
            },
            {
              "id": "C",
              "text": "Option C: Radionuclide cerebral perfusion scanning is not the preferred initial vascular study for suspected carotid-source transient ischemic attack."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transcranial Doppler ultrasonography is inappropriate because transcranial Doppler assesses intracranial arterial flow but is rated inappropriate as the initial imaging test for a resolved clinical TIA. The bruit and hemispheric symptoms specifically implicate the extracranial left carotid circulation, which carotid duplex examines directly."
        }
      }
    },
    {
      "externalId": "step3-obgyn-genital-herpes-pcr-3041",
      "expectedHashes": {
        "ranaze_step3_uat": "6444bd5287fb037893ea9e2715abf9c08a5a576f5fb12aac5af29e285b8d8266"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nucleic acid amplification testing of a cervical specimen for Chlamydia trachomatis is inappropriate because chlamydial infection usually causes cervicitis, urethritis, or pelvic inflammatory disease and does not explain grouped painful vulvar vesicles and ulcers."
            },
            {
              "id": "B",
              "text": "Option C: Dark-field microscopy of fluid from the base of an ulcer is inappropriate because dark-field microscopy may identify Treponema pallidum in a syphilitic chancre, which is typically painless and associated with nontender lymphadenopathy."
            },
            {
              "id": "C",
              "text": "Option D: Serologic testing for HIV infection is inappropriate because hIV testing is appropriate as part of sexually transmitted infection evaluation but does not establish the cause of the current genital lesions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nucleic acid amplification testing of a cervical specimen for Chlamydia trachomatis is inappropriate because chlamydial infection usually causes cervicitis, urethritis, or pelvic inflammatory disease and does not explain grouped painful vulvar vesicles and ulcers."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dark-field microscopy of fluid from the base of an ulcer is inappropriate because dark-field microscopy may identify Treponema pallidum in a syphilitic chancre, which is typically painless and associated with nontender lymphadenopathy."
            },
            {
              "id": "B",
              "text": "Option B: Nucleic acid amplification testing of a cervical specimen for Chlamydia trachomatis is inappropriate because chlamydial infection usually causes cervicitis, urethritis, or pelvic inflammatory disease and does not explain grouped painful vulvar vesicles and ulcers."
            },
            {
              "id": "C",
              "text": "Option D: Serologic testing for HIV infection is inappropriate because hIV testing is appropriate as part of sexually transmitted infection evaluation but does not establish the cause of the current genital lesions."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dark-field microscopy of fluid from the base of an ulcer is inappropriate because dark-field microscopy may identify Treponema pallidum in a syphilitic chancre, which is typically painless and associated with nontender lymphadenopathy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serologic testing for HIV infection is inappropriate because hIV testing is appropriate as part of sexually transmitted infection evaluation but does not establish the cause of the current genital lesions."
            },
            {
              "id": "B",
              "text": "Option B: Nucleic acid amplification testing of a cervical specimen for Chlamydia trachomatis is inappropriate because chlamydial infection usually causes cervicitis, urethritis, or pelvic inflammatory disease and does not explain grouped painful vulvar vesicles and ulcers."
            },
            {
              "id": "C",
              "text": "Option C: Dark-field microscopy of fluid from the base of an ulcer is inappropriate because dark-field microscopy may identify Treponema pallidum in a syphilitic chancre, which is typically painless and associated with nontender lymphadenopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serologic testing for HIV infection is inappropriate because hIV testing is appropriate as part of sexually transmitted infection evaluation but does not establish the cause of the current genital lesions."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gram stain of material scraped from the ulcer margin is inappropriate because gram staining does not diagnose herpes simplex virus and is not useful for identifying the viral cause of these lesions."
            },
            {
              "id": "B",
              "text": "Option B: Nucleic acid amplification testing of a cervical specimen for Chlamydia trachomatis is inappropriate because chlamydial infection usually causes cervicitis, urethritis, or pelvic inflammatory disease and does not explain grouped painful vulvar vesicles and ulcers."
            },
            {
              "id": "C",
              "text": "Option C: Dark-field microscopy of fluid from the base of an ulcer is inappropriate because dark-field microscopy may identify Treponema pallidum in a syphilitic chancre, which is typically painless and associated with nontender lymphadenopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gram stain of material scraped from the ulcer margin is inappropriate because gram staining does not diagnose herpes simplex virus and is not useful for identifying the viral cause of these lesions."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Type-specific serum HSV-2 IgG antibody testing is inappropriate because type-specific HSV-2 serology can assist when lesions are absent, symptoms are atypical with a negative lesion test, or a partner has genital herpes. It is inferior for establishing the cause of this active first episode because antibodies may not yet be detectable and HSV-1 serology cannot localize infection. Active vesicles should be sampled directly by HSV NAAT."
            },
            {
              "id": "B",
              "text": "Option B: Nucleic acid amplification testing of a cervical specimen for Chlamydia trachomatis is inappropriate because chlamydial infection usually causes cervicitis, urethritis, or pelvic inflammatory disease and does not explain grouped painful vulvar vesicles and ulcers."
            },
            {
              "id": "C",
              "text": "Option C: Dark-field microscopy of fluid from the base of an ulcer is inappropriate because dark-field microscopy may identify Treponema pallidum in a syphilitic chancre, which is typically painless and associated with nontender lymphadenopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Type-specific serum HSV-2 IgG antibody testing is inappropriate because type-specific HSV-2 serology can assist when lesions are absent, symptoms are atypical with a negative lesion test, or a partner has genital herpes. It is inferior for establishing the cause of this active first episode because antibodies may not yet be detectable and HSV-1 serology cannot localize infection. Active vesicles should be sampled directly by HSV NAAT."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Herpes simplex virus PCR testing of blood is inappropriate because blood HSV PCR is used when disseminated or systemic HSV infection is suspected, not to diagnose localized genital herpes. This afebrile, hemodynamically stable patient has lesions confined to the labium and no evidence of systemic disease, so the active lesion itself is the correct specimen."
            },
            {
              "id": "B",
              "text": "Option B: Nucleic acid amplification testing of a cervical specimen for Chlamydia trachomatis is inappropriate because chlamydial infection usually causes cervicitis, urethritis, or pelvic inflammatory disease and does not explain grouped painful vulvar vesicles and ulcers."
            },
            {
              "id": "C",
              "text": "Option C: Dark-field microscopy of fluid from the base of an ulcer is inappropriate because dark-field microscopy may identify Treponema pallidum in a syphilitic chancre, which is typically painless and associated with nontender lymphadenopathy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Herpes simplex virus PCR testing of blood is inappropriate because blood HSV PCR is used when disseminated or systemic HSV infection is suspected, not to diagnose localized genital herpes. This afebrile, hemodynamically stable patient has lesions confined to the labium and no evidence of systemic disease, so the active lesion itself is the correct specimen."
        }
      }
    },
    {
      "externalId": "step3-obstetrics-initial-prenatal-blood-type-1024",
      "expectedHashes": {
        "ranaze_step3_uat": "212231b8bf058491be68822c35f5ae17ffdf2ef9699f794610a7bafcb1134e35",
        "ranaze_step3_prd": "212231b8bf058491be68822c35f5ae17ffdf2ef9699f794610a7bafcb1134e35"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Amniocentesis for fetal karyotyping is inappropriate because amniocentesis is an optional invasive diagnostic test rather than a universal initial maternal laboratory study, and it is generally performed at 15 weeks or later after informed counseling."
            },
            {
              "id": "B",
              "text": "Option C: Vaginal-rectal culture for group B Streptococcus is inappropriate because routine group B Streptococcus screening is performed at 36 0/7 through 37 6/7 weeks unless an earlier clinical circumstance already establishes the need for intrapartum prophylaxis."
            },
            {
              "id": "C",
              "text": "Option D: Repeat transvaginal ultrasonography to confirm viability is inappropriate because viability and intrauterine location were documented recently; repeat ultrasonography is not a maternal laboratory study and is not the most important universal test listed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Amniocentesis for fetal karyotyping is inappropriate because amniocentesis is an optional invasive diagnostic test rather than a universal initial maternal laboratory study, and it is generally performed at 15 weeks or later after informed counseling."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Vaginal-rectal culture for group B Streptococcus is inappropriate because routine group B Streptococcus screening is performed at 36 0/7 through 37 6/7 weeks unless an earlier clinical circumstance already establishes the need for intrapartum prophylaxis."
            },
            {
              "id": "B",
              "text": "Option B: Amniocentesis for fetal karyotyping is inappropriate because amniocentesis is an optional invasive diagnostic test rather than a universal initial maternal laboratory study, and it is generally performed at 15 weeks or later after informed counseling."
            },
            {
              "id": "C",
              "text": "Option D: Repeat transvaginal ultrasonography to confirm viability is inappropriate because viability and intrauterine location were documented recently; repeat ultrasonography is not a maternal laboratory study and is not the most important universal test listed."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Vaginal-rectal culture for group B Streptococcus is inappropriate because routine group B Streptococcus screening is performed at 36 0/7 through 37 6/7 weeks unless an earlier clinical circumstance already establishes the need for intrapartum prophylaxis."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat transvaginal ultrasonography to confirm viability is inappropriate because viability and intrauterine location were documented recently; repeat ultrasonography is not a maternal laboratory study and is not the most important universal test listed."
            },
            {
              "id": "B",
              "text": "Option B: Amniocentesis for fetal karyotyping is inappropriate because amniocentesis is an optional invasive diagnostic test rather than a universal initial maternal laboratory study, and it is generally performed at 15 weeks or later after informed counseling."
            },
            {
              "id": "C",
              "text": "Option C: Vaginal-rectal culture for group B Streptococcus is inappropriate because routine group B Streptococcus screening is performed at 36 0/7 through 37 6/7 weeks unless an earlier clinical circumstance already establishes the need for intrapartum prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat transvaginal ultrasonography to confirm viability is inappropriate because viability and intrauterine location were documented recently; repeat ultrasonography is not a maternal laboratory study and is not the most important universal test listed."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal serum alpha-fetoprotein measurement is inappropriate because maternal serum alpha-fetoprotein may be used for second-trimester screening for open neural tube defects and is not obtained at 9 weeks."
            },
            {
              "id": "B",
              "text": "Option B: Amniocentesis for fetal karyotyping is inappropriate because amniocentesis is an optional invasive diagnostic test rather than a universal initial maternal laboratory study, and it is generally performed at 15 weeks or later after informed counseling."
            },
            {
              "id": "C",
              "text": "Option C: Vaginal-rectal culture for group B Streptococcus is inappropriate because routine group B Streptococcus screening is performed at 36 0/7 through 37 6/7 weeks unless an earlier clinical circumstance already establishes the need for intrapartum prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal serum alpha-fetoprotein measurement is inappropriate because maternal serum alpha-fetoprotein may be used for second-trimester screening for open neural tube defects and is not obtained at 9 weeks."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain cell-free DNA screening for fetal aneuploidy immediately at 9 weeks is inappropriate because cell-free DNA screening should be discussed and offered, but it is optional rather than a universal initial prenatal laboratory requirement and generally begins at 10 weeks. At 9 weeks, routine maternal ABO/Rh typing and antibody screening should be completed first."
            },
            {
              "id": "B",
              "text": "Option B: Amniocentesis for fetal karyotyping is inappropriate because amniocentesis is an optional invasive diagnostic test rather than a universal initial maternal laboratory study, and it is generally performed at 15 weeks or later after informed counseling."
            },
            {
              "id": "C",
              "text": "Option C: Vaginal-rectal culture for group B Streptococcus is inappropriate because routine group B Streptococcus screening is performed at 36 0/7 through 37 6/7 weeks unless an earlier clinical circumstance already establishes the need for intrapartum prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain cell-free DNA screening for fetal aneuploidy immediately at 9 weeks is inappropriate because cell-free DNA screening should be discussed and offered, but it is optional rather than a universal initial prenatal laboratory requirement and generally begins at 10 weeks. At 9 weeks, routine maternal ABO/Rh typing and antibody screening should be completed first."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Measure serial quantitative serum beta-human chorionic gonadotropin levels is inappropriate because serial beta-hCG measurements help evaluate a pregnancy of unknown location or uncertain viability. This patient\u0027s viable intrauterine pregnancy was documented by ultrasonography and fetal cardiac activity remains present, so serial testing is unnecessary."
            },
            {
              "id": "B",
              "text": "Option B: Amniocentesis for fetal karyotyping is inappropriate because amniocentesis is an optional invasive diagnostic test rather than a universal initial maternal laboratory study, and it is generally performed at 15 weeks or later after informed counseling."
            },
            {
              "id": "C",
              "text": "Option C: Vaginal-rectal culture for group B Streptococcus is inappropriate because routine group B Streptococcus screening is performed at 36 0/7 through 37 6/7 weeks unless an earlier clinical circumstance already establishes the need for intrapartum prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Measure serial quantitative serum beta-human chorionic gonadotropin levels is inappropriate because serial beta-hCG measurements help evaluate a pregnancy of unknown location or uncertain viability. This patient\u0027s viable intrauterine pregnancy was documented by ultrasonography and fetal cardiac activity remains present, so serial testing is unnecessary."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain the oocyte donor\u0027s ABO and Rh(D) type and antibody screen instead of testing the pregnant patient is inappropriate because alloimmunization management depends on the blood group, Rh status, and antibodies of the person carrying the pregnancy. The donor\u0027s blood type cannot substitute for the pregnant patient\u0027s routine testing."
            },
            {
              "id": "B",
              "text": "Option B: Amniocentesis for fetal karyotyping is inappropriate because amniocentesis is an optional invasive diagnostic test rather than a universal initial maternal laboratory study, and it is generally performed at 15 weeks or later after informed counseling."
            },
            {
              "id": "C",
              "text": "Option C: Vaginal-rectal culture for group B Streptococcus is inappropriate because routine group B Streptococcus screening is performed at 36 0/7 through 37 6/7 weeks unless an earlier clinical circumstance already establishes the need for intrapartum prophylaxis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain the oocyte donor\u0027s ABO and Rh(D) type and antibody screen instead of testing the pregnant patient is inappropriate because alloimmunization management depends on the blood group, Rh status, and antibodies of the person carrying the pregnancy. The donor\u0027s blood type cannot substitute for the pregnant patient\u0027s routine testing."
        }
      }
    },
    {
      "externalId": "step3-obstetrics-polyhydramnios-esophageal-atresia-1329",
      "expectedHashes": {
        "ranaze_step3_uat": "16bcf8385162a8d6d3a4f394a453ec8500817ab3b2e67e2c7730fe749266a411"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
            },
            {
              "id": "B",
              "text": "Option C: Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
            },
            {
              "id": "C",
              "text": "Option D: Fetal posterior urethral valves is inappropriate because posterior urethral valves cause urinary tract obstruction, an enlarged bladder, hydronephrosis, and oligohydramnios rather than polyhydramnios."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
            },
            {
              "id": "B",
              "text": "Option B: Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
            },
            {
              "id": "C",
              "text": "Option D: Fetal posterior urethral valves is inappropriate because posterior urethral valves cause urinary tract obstruction, an enlarged bladder, hydronephrosis, and oligohydramnios rather than polyhydramnios."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fetal posterior urethral valves is inappropriate because posterior urethral valves cause urinary tract obstruction, an enlarged bladder, hydronephrosis, and oligohydramnios rather than polyhydramnios."
            },
            {
              "id": "B",
              "text": "Option B: Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
            },
            {
              "id": "C",
              "text": "Option C: Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fetal posterior urethral valves is inappropriate because posterior urethral valves cause urinary tract obstruction, an enlarged bladder, hydronephrosis, and oligohydramnios rather than polyhydramnios."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A complete hydatidiform mole does not contain a normal fetus and typically presents earlier with markedly elevated beta-hCG, uterine enlargement, and a characteristic intrauterine vesicular pattern."
            },
            {
              "id": "B",
              "text": "Option B: Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
            },
            {
              "id": "C",
              "text": "Option C: Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A complete hydatidiform mole does not contain a normal fetus and typically presents earlier with markedly elevated beta-hCG, uterine enlargement, and a characteristic intrauterine vesicular pattern."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal gestational diabetes mellitus is inappropriate because maternal diabetes is a common cause of polyhydramnios through increased fetal urine production, but it does not explain a persistently small or absent fetal gastric bubble. That finding instead indicates impaired passage of swallowed fluid into the stomach."
            },
            {
              "id": "B",
              "text": "Option B: Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
            },
            {
              "id": "C",
              "text": "Option C: Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal gestational diabetes mellitus is inappropriate because maternal diabetes is a common cause of polyhydramnios through increased fetal urine production, but it does not explain a persistently small or absent fetal gastric bubble. That finding instead indicates impaired passage of swallowed fluid into the stomach."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fetal duodenal atresia is inappropriate because duodenal atresia causes polyhydramnios but permits swallowed fluid to enter and distend the stomach and proximal duodenum, producing the characteristic double-bubble appearance rather than a persistently absent stomach."
            },
            {
              "id": "B",
              "text": "Option B: Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
            },
            {
              "id": "C",
              "text": "Option C: Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fetal duodenal atresia is inappropriate because duodenal atresia causes polyhydramnios but permits swallowed fluid to enter and distend the stomach and proximal duodenum, producing the characteristic double-bubble appearance rather than a persistently absent stomach."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Idiopathic polyhydramnios is inappropriate because many cases of mild polyhydramnios are idiopathic, but marked polyhydramnios accompanied by a persistent structural clue\u2014an absent or small gastric bubble\u2014should not be classified as idiopathic."
            },
            {
              "id": "B",
              "text": "Option B: Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
            },
            {
              "id": "C",
              "text": "Option C: Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Idiopathic polyhydramnios is inappropriate because many cases of mild polyhydramnios are idiopathic, but marked polyhydramnios accompanied by a persistent structural clue\u2014an absent or small gastric bubble\u2014should not be classified as idiopathic."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Isolated H-type tracheoesophageal fistula without esophageal atresia is inappropriate because an isolated H-type tracheoesophageal fistula leaves the esophagus patent, allowing the fetus to swallow fluid into the stomach. It therefore does not account for a persistently small or absent gastric bubble."
            },
            {
              "id": "B",
              "text": "Option B: Bilateral fetal renal agenesis is inappropriate because bilateral renal agenesis causes severe oligohydramnios because fetal urine production is absent; the kidneys and bladder would not appear normal."
            },
            {
              "id": "C",
              "text": "Option C: Maternal chronic hypertension is associated with uteroplacental insufficiency, fetal growth restriction, and oligohydramnios rather than marked polyhydramnios with an absent gastric bubble."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Isolated H-type tracheoesophageal fistula without esophageal atresia is inappropriate because an isolated H-type tracheoesophageal fistula leaves the esophagus patent, allowing the fetus to swallow fluid into the stomach. It therefore does not account for a persistently small or absent gastric bubble."
        }
      }
    },
    {
      "externalId": "step3-obstetrics-postpartum-hemorrhage-uterine-atony-1763",
      "expectedHashes": {
        "ranaze_step3_uat": "25e41bc1f44432014288050dfd54ebf00608a73e47daf86f77a7718a08b1c5a9",
        "ranaze_step3_prd": "25e41bc1f44432014288050dfd54ebf00608a73e47daf86f77a7718a08b1c5a9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cervical integrity is inappropriate because cervical laceration should be considered when bleeding persists despite a firm, well-contracted uterus, but uterine tone should be evaluated first."
            },
            {
              "id": "B",
              "text": "Option C: Appearance of the delivered placenta is inappropriate because inspection of the placenta helps identify retained placental fragments, but the placenta was delivered intact and uterine atony remains more common."
            },
            {
              "id": "C",
              "text": "Option D: Coagulation of collected blood is inappropriate because failure of blood to clot may suggest coagulopathy, but this is less common than uterine atony and is not the first focused examination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cervical integrity is inappropriate because cervical laceration should be considered when bleeding persists despite a firm, well-contracted uterus, but uterine tone should be evaluated first."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Appearance of the delivered placenta is inappropriate because inspection of the placenta helps identify retained placental fragments, but the placenta was delivered intact and uterine atony remains more common."
            },
            {
              "id": "B",
              "text": "Option B: Cervical integrity is inappropriate because cervical laceration should be considered when bleeding persists despite a firm, well-contracted uterus, but uterine tone should be evaluated first."
            },
            {
              "id": "C",
              "text": "Option D: Coagulation of collected blood is inappropriate because failure of blood to clot may suggest coagulopathy, but this is less common than uterine atony and is not the first focused examination."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Appearance of the delivered placenta is inappropriate because inspection of the placenta helps identify retained placental fragments, but the placenta was delivered intact and uterine atony remains more common."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Coagulation of collected blood is inappropriate because failure of blood to clot may suggest coagulopathy, but this is less common than uterine atony and is not the first focused examination."
            },
            {
              "id": "B",
              "text": "Option B: Cervical integrity is inappropriate because cervical laceration should be considered when bleeding persists despite a firm, well-contracted uterus, but uterine tone should be evaluated first."
            },
            {
              "id": "C",
              "text": "Option C: Appearance of the delivered placenta is inappropriate because inspection of the placenta helps identify retained placental fragments, but the placenta was delivered intact and uterine atony remains more common."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Coagulation of collected blood is inappropriate because failure of blood to clot may suggest coagulopathy, but this is less common than uterine atony and is not the first focused examination."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lower-extremity deep tendon reflexes is inappropriate because deep tendon reflexes may be relevant in patients receiving magnesium sulfate but do not identify the source of postpartum bleeding."
            },
            {
              "id": "B",
              "text": "Option B: Cervical integrity is inappropriate because cervical laceration should be considered when bleeding persists despite a firm, well-contracted uterus, but uterine tone should be evaluated first."
            },
            {
              "id": "C",
              "text": "Option C: Appearance of the delivered placenta is inappropriate because inspection of the placenta helps identify retained placental fragments, but the placenta was delivered intact and uterine atony remains more common."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lower-extremity deep tendon reflexes is inappropriate because deep tendon reflexes may be relevant in patients receiving magnesium sulfate but do not identify the source of postpartum bleeding."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bedside pelvic ultrasonography for retained placental tissue is inappropriate because ultrasonography can help evaluate suspected retained tissue, but the placenta was delivered intact and imaging should not delay the rapid bedside assessment for uterine atony, the most common cause of immediate postpartum hemorrhage."
            },
            {
              "id": "B",
              "text": "Option B: Cervical integrity is inappropriate because cervical laceration should be considered when bleeding persists despite a firm, well-contracted uterus, but uterine tone should be evaluated first."
            },
            {
              "id": "C",
              "text": "Option C: Appearance of the delivered placenta is inappropriate because inspection of the placenta helps identify retained placental fragments, but the placenta was delivered intact and uterine atony remains more common."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bedside pelvic ultrasonography for retained placental tissue is inappropriate because ultrasonography can help evaluate suspected retained tissue, but the placenta was delivered intact and imaging should not delay the rapid bedside assessment for uterine atony, the most common cause of immediate postpartum hemorrhage."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediate manual exploration of the uterine cavity is inappropriate because manual uterine exploration may be required when retained tissue is suspected, but it is invasive and is not the first examination when the placenta appears intact. Fundal palpation should first establish whether atony is present."
            },
            {
              "id": "B",
              "text": "Option B: Cervical integrity is inappropriate because cervical laceration should be considered when bleeding persists despite a firm, well-contracted uterus, but uterine tone should be evaluated first."
            },
            {
              "id": "C",
              "text": "Option C: Appearance of the delivered placenta is inappropriate because inspection of the placenta helps identify retained placental fragments, but the placenta was delivered intact and uterine atony remains more common."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediate manual exploration of the uterine cavity is inappropriate because manual uterine exploration may be required when retained tissue is suspected, but it is invasive and is not the first examination when the placenta appears intact. Fundal palpation should first establish whether atony is present."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Palpation for a concealed vulvovaginal hematoma is inappropriate because a concealed vulvovaginal hematoma more often produces pain, pressure, swelling, or otherwise unexplained blood loss rather than brisk externally visible bleeding. It is less likely here and does not supersede assessment of uterine tone."
            },
            {
              "id": "B",
              "text": "Option B: Cervical integrity is inappropriate because cervical laceration should be considered when bleeding persists despite a firm, well-contracted uterus, but uterine tone should be evaluated first."
            },
            {
              "id": "C",
              "text": "Option C: Appearance of the delivered placenta is inappropriate because inspection of the placenta helps identify retained placental fragments, but the placenta was delivered intact and uterine atony remains more common."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Palpation for a concealed vulvovaginal hematoma is inappropriate because a concealed vulvovaginal hematoma more often produces pain, pressure, swelling, or otherwise unexplained blood loss rather than brisk externally visible bleeding. It is less likely here and does not supersede assessment of uterine tone."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-abusive-head-trauma-ct-447",
      "expectedHashes": {
        "ranaze_step3_uat": "b5113af64049eaf4fc4883ce601adb34ece77c9188aeb9f4fcdd4580bd58a356",
        "ranaze_step3_prd": "b5113af64049eaf4fc4883ce601adb34ece77c9188aeb9f4fcdd4580bd58a356"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "B",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            },
            {
              "id": "C",
              "text": "Option D: A complete skeletal survey is required to detect occult fractures in suspected abuse but is not the first study in an infant with signs of acute intracranial injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option D: A complete skeletal survey is required to detect occult fractures in suspected abuse but is not the first study in an infant with signs of acute intracranial injury."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A complete skeletal survey is required to detect occult fractures in suspected abuse but is not the first study in an infant with signs of acute intracranial injury."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A complete skeletal survey is required to detect occult fractures in suspected abuse but is not the first study in an infant with signs of acute intracranial injury."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum electrolyte measurements is inappropriate because electrolyte testing can evaluate metabolic seizure triggers and may be obtained concurrently, but it should not delay urgent structural imaging in this presentation."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum electrolyte measurements is inappropriate because electrolyte testing can evaluate metabolic seizure triggers and may be obtained concurrently, but it should not delay urgent structural imaging in this presentation."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the brain without contrast is inappropriate because brain MRI can characterize parenchymal, ischemic, and subtle traumatic injuries and is often obtained after CT. It is not the next study in an acutely unresponsive infant with signs of increased intracranial pressure because noncontrast CT is faster and promptly identifies acute hemorrhage and mass effect."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the brain without contrast is inappropriate because brain MRI can characterize parenchymal, ischemic, and subtle traumatic injuries and is often obtained after CT. It is not the next study in an acutely unresponsive infant with signs of increased intracranial pressure because noncontrast CT is faster and promptly identifies acute hemorrhage and mass effect."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cranial ultrasonography through the anterior fontanelle is inappropriate because cranial ultrasonography is portable but cannot comprehensively evaluate the extra-axial spaces, cerebral convexities, skull, and other traumatic injuries. It cannot replace urgent CT in this neurologically unstable infant."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cranial ultrasonography through the anterior fontanelle is inappropriate because cranial ultrasonography is portable but cannot comprehensively evaluate the extra-axial spaces, cerebral convexities, skull, and other traumatic injuries. It cannot replace urgent CT in this neurologically unstable infant."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Contrast-enhanced CT scan of the head is inappropriate because intravenous contrast is unnecessary for the initial detection of acute traumatic hemorrhage and may obscure small amounts of hyperdense blood. The indicated initial examination is CT of the head without contrast."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Contrast-enhanced CT scan of the head is inappropriate because intravenous contrast is unnecessary for the initial detection of acute traumatic hemorrhage and may obscure small amounts of hyperdense blood. The indicated initial examination is CT of the head without contrast."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the cervical spine is inappropriate because cervical-spine MRI may subsequently detect associated ligamentous or spinal injury in abusive head trauma, commonly when brain MRI is performed. It must not precede emergency evaluation of the intracranial process causing unresponsiveness, a tense fontanelle, and anisocoria."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the cervical spine is inappropriate because cervical-spine MRI may subsequently detect associated ligamentous or spinal injury in abusive head trauma, commonly when brain MRI is performed. It must not precede emergency evaluation of the intracranial process causing unresponsiveness, a tense fontanelle, and anisocoria."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Coagulation studies may help evaluate a bleeding disorder or an alternative contributor to hemorrhage, but laboratory evaluation cannot exclude acute intracranial bleeding or mass effect and must not delay emergency head CT."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Coagulation studies may help evaluate a bleeding disorder or an alternative contributor to hemorrhage, but laboratory evaluation cannot exclude acute intracranial bleeding or mass effect and must not delay emergency head CT."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Formal dilated ophthalmologic examination is inappropriate because a detailed examination by an ophthalmologist is part of the subsequent abusive-head-trauma evaluation. Bilateral multilayered retinal hemorrhages have already been identified, however, and repeating or documenting the eye examination cannot assess the immediately threatening intracranial lesion."
            },
            {
              "id": "B",
              "text": "Option B: Electroencephalography may be useful for persistent or nonconvulsive seizures but does not identify the structural intracranial injury suggested by the tense fontanelle, anisocoria, and retinal hemorrhages."
            },
            {
              "id": "C",
              "text": "Option C: Lumbar puncture with cerebrospinal fluid analysis is inappropriate because lumbar puncture is unsafe before neuroimaging because the tense fontanelle and unequal pupils suggest increased intracranial pressure and possible mass effect."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Formal dilated ophthalmologic examination is inappropriate because a detailed examination by an ophthalmologist is part of the subsequent abusive-head-trauma evaluation. Bilateral multilayered retinal hemorrhages have already been identified, however, and repeating or documenting the eye examination cannot assess the immediately threatening intracranial lesion."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-adolescent-asthma-environmental-trigger-1542",
      "expectedHashes": {
        "ranaze_step3_uat": "76b145af187559c60bcdf31f5726220e5b6ef6b2363ad7431b172f89cffe3c9c",
        "ranaze_step3_prd": "76b145af187559c60bcdf31f5726220e5b6ef6b2363ad7431b172f89cffe3c9c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
            },
            {
              "id": "B",
              "text": "Option C: Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
            },
            {
              "id": "C",
              "text": "Option D: Review his academic performance is inappropriate because school performance is an important component of adolescent care but is not the most likely explanation for the recent deterioration in asthma control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
            },
            {
              "id": "B",
              "text": "Option B: Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
            },
            {
              "id": "C",
              "text": "Option D: Review his academic performance is inappropriate because school performance is an important component of adolescent care but is not the most likely explanation for the recent deterioration in asthma control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Review his academic performance is inappropriate because school performance is an important component of adolescent care but is not the most likely explanation for the recent deterioration in asthma control."
            },
            {
              "id": "B",
              "text": "Option B: Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Review his academic performance is inappropriate because school performance is an important component of adolescent care but is not the most likely explanation for the recent deterioration in asthma control."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask whether he is obtaining enough sleep is inappropriate because sleep should be assessed in adolescents, but it does not explain the temporal association between symptoms and a new environment."
            },
            {
              "id": "B",
              "text": "Option B: Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask whether he is obtaining enough sleep is inappropriate because sleep should be assessed in adolescents, but it does not explain the temporal association between symptoms and a new environment."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask whether he has had recurrent upper respiratory infection symptoms is inappropriate because respiratory infections can exacerbate asthma, but a recurrent infection does not explain three months of symptoms that are specifically worse on weekends after exposure to a new residence."
            },
            {
              "id": "B",
              "text": "Option B: Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask whether he has had recurrent upper respiratory infection symptoms is inappropriate because respiratory infections can exacerbate asthma, but a recurrent infection does not explain three months of symptoms that are specifically worse on weekends after exposure to a new residence."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask whether his symptoms worsen during exercise is inappropriate because exercise-related symptoms remain relevant given his previous pre-exercise albuterol use. The new deterioration, however, is linked more directly to weekends at his girlfriend\u0027s house than to exercise."
            },
            {
              "id": "B",
              "text": "Option B: Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask whether his symptoms worsen during exercise is inappropriate because exercise-related symptoms remain relevant given his previous pre-exercise albuterol use. The new deterioration, however, is linked more directly to weekends at his girlfriend\u0027s house than to exercise."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask whether he has heartburn or a sour taste in his mouth is inappropriate because gastroesophageal reflux can aggravate respiratory symptoms, but the stem supplies no meal-related or positional pattern and instead gives a strong exposure-related weekend pattern."
            },
            {
              "id": "B",
              "text": "Option B: Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask whether he has heartburn or a sour taste in his mouth is inappropriate because gastroesophageal reflux can aggravate respiratory symptoms, but the stem supplies no meal-related or positional pattern and instead gives a strong exposure-related weekend pattern."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ask whether his asthma symptoms worsen while he is at school is inappropriate because school exposures can affect asthma and missed school demonstrates morbidity. Symptoms are reported to be worse on weekends, making the girlfriend\u0027s home the more relevant setting to investigate first."
            },
            {
              "id": "B",
              "text": "Option B: Screen for illicit drug use is inappropriate because adolescents should be screened confidentially for substance use, but the history strongly suggests an environmental trigger that should be clarified as part of the current asthma evaluation."
            },
            {
              "id": "C",
              "text": "Option C: Ask about conflict between him and his father is inappropriate because assessing family relationships is appropriate during adolescent visits but is less directly related to the current worsening of asthma."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ask whether his asthma symptoms worsen while he is at school is inappropriate because school exposures can affect asthma and missed school demonstrates morbidity. Symptoms are reported to be worse on weekends, making the girlfriend\u0027s home the more relevant setting to investigate first."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-bullous-myringitis-2573",
      "expectedHashes": {
        "ranaze_step3_uat": "fa60573af0426b04e0eff30e771e507fba64efdae1a6c6810b4294d2226ed190",
        "ranaze_step3_prd": "fa60573af0426b04e0eff30e771e507fba64efdae1a6c6810b4294d2226ed190"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute otitis externa is inappropriate because otitis externa causes inflammation of the external auditory canal with pain on manipulation of the tragus or pinna, canal edema, and often discharge."
            },
            {
              "id": "B",
              "text": "Option C: Otitis media with effusion causes middle-ear fluid and conductive hearing symptoms without acute severe pain, fever, or tympanic membrane bullae."
            },
            {
              "id": "C",
              "text": "Option D: Traumatic tympanic membrane perforation is inappropriate because traumatic perforation usually follows barotrauma or insertion of an object and causes a visible defect in the tympanic membrane rather than intact bullae."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute otitis externa is inappropriate because otitis externa causes inflammation of the external auditory canal with pain on manipulation of the tragus or pinna, canal edema, and often discharge."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Otitis media with effusion causes middle-ear fluid and conductive hearing symptoms without acute severe pain, fever, or tympanic membrane bullae."
            },
            {
              "id": "B",
              "text": "Option B: Acute otitis externa is inappropriate because otitis externa causes inflammation of the external auditory canal with pain on manipulation of the tragus or pinna, canal edema, and often discharge."
            },
            {
              "id": "C",
              "text": "Option D: Traumatic tympanic membrane perforation is inappropriate because traumatic perforation usually follows barotrauma or insertion of an object and causes a visible defect in the tympanic membrane rather than intact bullae."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Otitis media with effusion causes middle-ear fluid and conductive hearing symptoms without acute severe pain, fever, or tympanic membrane bullae."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Traumatic tympanic membrane perforation is inappropriate because traumatic perforation usually follows barotrauma or insertion of an object and causes a visible defect in the tympanic membrane rather than intact bullae."
            },
            {
              "id": "B",
              "text": "Option B: Acute otitis externa is inappropriate because otitis externa causes inflammation of the external auditory canal with pain on manipulation of the tragus or pinna, canal edema, and often discharge."
            },
            {
              "id": "C",
              "text": "Option C: Otitis media with effusion causes middle-ear fluid and conductive hearing symptoms without acute severe pain, fever, or tympanic membrane bullae."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Traumatic tympanic membrane perforation is inappropriate because traumatic perforation usually follows barotrauma or insertion of an object and causes a visible defect in the tympanic membrane rather than intact bullae."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Herpes zoster oticus usually causes painful vesicles of the auricle or external ear canal and may be accompanied by ipsilateral facial weakness."
            },
            {
              "id": "B",
              "text": "Option B: Acute otitis externa is inappropriate because otitis externa causes inflammation of the external auditory canal with pain on manipulation of the tragus or pinna, canal edema, and often discharge."
            },
            {
              "id": "C",
              "text": "Option C: Otitis media with effusion causes middle-ear fluid and conductive hearing symptoms without acute severe pain, fever, or tympanic membrane bullae."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Herpes zoster oticus usually causes painful vesicles of the auricle or external ear canal and may be accompanied by ipsilateral facial weakness."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute mastoiditis causes postauricular pain, erythema, tenderness, or swelling with displacement of the pinna. Tense bullae directly on the tympanic membrane instead identify bullous myringitis."
            },
            {
              "id": "B",
              "text": "Option B: Acute otitis externa is inappropriate because otitis externa causes inflammation of the external auditory canal with pain on manipulation of the tragus or pinna, canal edema, and often discharge."
            },
            {
              "id": "C",
              "text": "Option C: Otitis media with effusion causes middle-ear fluid and conductive hearing symptoms without acute severe pain, fever, or tympanic membrane bullae."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute mastoiditis causes postauricular pain, erythema, tenderness, or swelling with displacement of the pinna. Tense bullae directly on the tympanic membrane instead identify bullous myringitis."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-congenital-cmv-638",
      "expectedHashes": {
        "ranaze_step3_uat": "5eec88e0a493f034c98e5b10168d883006c928d8223d3985c170bdf1d9556bca",
        "ranaze_step3_prd": "5eec88e0a493f034c98e5b10168d883006c928d8223d3985c170bdf1d9556bca"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "B",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            },
            {
              "id": "C",
              "text": "Option D: Radiographs of the long bones is inappropriate because long-bone radiographs are useful in congenital syphilis, which can cause periostitis and metaphyseal abnormalities."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option D: Radiographs of the long bones is inappropriate because long-bone radiographs are useful in congenital syphilis, which can cause periostitis and metaphyseal abnormalities."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Radiographs of the long bones is inappropriate because long-bone radiographs are useful in congenital syphilis, which can cause periostitis and metaphyseal abnormalities."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Radiographs of the long bones is inappropriate because long-bone radiographs are useful in congenital syphilis, which can cause periostitis and metaphyseal abnormalities."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Peripheral blood smear for abnormal erythrocyte morphology is inappropriate because a peripheral smear may evaluate hematologic disorders but does not establish the cause of congenital periventricular calcifications and hepatosplenomegaly."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Peripheral blood smear for abnormal erythrocyte morphology is inappropriate because a peripheral smear may evaluate hematologic disorders but does not establish the cause of congenital periventricular calcifications and hepatosplenomegaly."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum cytomegalovirus IgG antibody testing in the infant is inappropriate because infant CMV IgG may represent transplacentally transferred maternal antibody and therefore cannot confirm congenital infection. The infant\u0027s characteristic findings require direct viral detection."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum cytomegalovirus IgG antibody testing in the infant is inappropriate because infant CMV IgG may represent transplacentally transferred maternal antibody and therefore cannot confirm congenital infection. The infant\u0027s characteristic findings require direct viral detection."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Maternal cytomegalovirus IgG avidity testing is inappropriate because maternal IgG avidity can help estimate the timing of a primary maternal infection, but it neither proves nor excludes fetal transmission and cannot confirm infection in this newborn."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Maternal cytomegalovirus IgG avidity testing is inappropriate because maternal IgG avidity can help estimate the timing of a primary maternal infection, but it neither proves nor excludes fetal transmission and cannot confirm infection in this newborn."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum rubella-specific IgM antibody testing in the infant is inappropriate because rubella IgM can support congenital rubella syndrome, but congenital rubella more characteristically causes cataracts, hearing impairment, and congenital heart disease. The periventricular calcifications, thrombocytopenia, microcephaly, and growth restriction strongly favor CMV."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum rubella-specific IgM antibody testing in the infant is inappropriate because rubella IgM can support congenital rubella syndrome, but congenital rubella more characteristically causes cataracts, hearing impairment, and congenital heart disease. The periventricular calcifications, thrombocytopenia, microcephaly, and growth restriction strongly favor CMV."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Zika virus nucleic acid testing of infant serum and urine is inappropriate because congenital Zika infection can cause microcephaly and intracranial calcifications, but the calcifications are characteristically cortical-subcortical, and testing is indicated in the setting of maternal exposure. This infant\u0027s periventricular calcifications and systemic CMV manifestations make urine CMV PCR the appropriate confirmation."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Zika virus nucleic acid testing of infant serum and urine is inappropriate because congenital Zika infection can cause microcephaly and intracranial calcifications, but the calcifications are characteristically cortical-subcortical, and testing is indicated in the setting of maternal exposure. This infant\u0027s periventricular calcifications and systemic CMV manifestations make urine CMV PCR the appropriate confirmation."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cerebrospinal fluid polymerase chain reaction testing for herpes simplex virus is inappropriate because cSF HSV PCR is used when neonatal herpes encephalitis is suspected, usually with illness such as fever, seizures, lethargy, or vesicular disease. It does not explain the congenital periventricular calcifications and growth restriction present on day 2."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cerebrospinal fluid polymerase chain reaction testing for herpes simplex virus is inappropriate because cSF HSV PCR is used when neonatal herpes encephalitis is suspected, usually with illness such as fever, seizures, lethargy, or vesicular disease. It does not explain the congenital periventricular calcifications and growth restriction present on day 2."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Dilated ophthalmologic examination is inappropriate because an ophthalmologic examination can identify chorioretinitis or other ocular complications and may help assess competing congenital infections, but normal or abnormal ocular findings do not confirm congenital CMV."
            },
            {
              "id": "B",
              "text": "Option B: Serum Toxoplasma gondii IgM antibody testing is inappropriate because congenital toxoplasmosis typically produces diffuse rather than periventricular intracranial calcifications and is commonly associated with chorioretinitis and hydrocephalus."
            },
            {
              "id": "C",
              "text": "Option C: Rapid plasma reagin testing is inappropriate because rapid plasma reagin is used when congenital syphilis is suspected but does not best fit this infant\u0027s imaging findings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Dilated ophthalmologic examination is inappropriate because an ophthalmologic examination can identify chorioretinitis or other ocular complications and may help assess competing congenital infections, but normal or abnormal ocular findings do not confirm congenital CMV."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-croup-laryngotracheitis-2917",
      "expectedHashes": {
        "ranaze_step3_uat": "cca69a9b1e338095ffcf7fc9aebffaf238b927818e2a6683e711b0a295324b13",
        "ranaze_step3_prd": "cca69a9b1e338095ffcf7fc9aebffaf238b927818e2a6683e711b0a295324b13"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute epiglottitis is inappropriate because epiglottitis typically causes abrupt high fever, severe sore throat, drooling, dysphagia, muffled voice, and tripod positioning without a prominent barking cough."
            },
            {
              "id": "B",
              "text": "Option C: Bacterial tracheitis generally causes high fever, toxic appearance, progressive airway obstruction, and thick purulent secretions, often after an initial viral illness."
            },
            {
              "id": "C",
              "text": "Option D: Viral bronchiolitis is inappropriate because bronchiolitis typically occurs in infants and causes wheezing, crackles, tachypnea, and lower-airway obstruction rather than barking cough and inspiratory stridor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute epiglottitis is inappropriate because epiglottitis typically causes abrupt high fever, severe sore throat, drooling, dysphagia, muffled voice, and tripod positioning without a prominent barking cough."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bacterial tracheitis generally causes high fever, toxic appearance, progressive airway obstruction, and thick purulent secretions, often after an initial viral illness."
            },
            {
              "id": "B",
              "text": "Option B: Acute epiglottitis is inappropriate because epiglottitis typically causes abrupt high fever, severe sore throat, drooling, dysphagia, muffled voice, and tripod positioning without a prominent barking cough."
            },
            {
              "id": "C",
              "text": "Option D: Viral bronchiolitis is inappropriate because bronchiolitis typically occurs in infants and causes wheezing, crackles, tachypnea, and lower-airway obstruction rather than barking cough and inspiratory stridor."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bacterial tracheitis generally causes high fever, toxic appearance, progressive airway obstruction, and thick purulent secretions, often after an initial viral illness."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Viral bronchiolitis is inappropriate because bronchiolitis typically occurs in infants and causes wheezing, crackles, tachypnea, and lower-airway obstruction rather than barking cough and inspiratory stridor."
            },
            {
              "id": "B",
              "text": "Option B: Acute epiglottitis is inappropriate because epiglottitis typically causes abrupt high fever, severe sore throat, drooling, dysphagia, muffled voice, and tripod positioning without a prominent barking cough."
            },
            {
              "id": "C",
              "text": "Option C: Bacterial tracheitis generally causes high fever, toxic appearance, progressive airway obstruction, and thick purulent secretions, often after an initial viral illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Viral bronchiolitis is inappropriate because bronchiolitis typically occurs in infants and causes wheezing, crackles, tachypnea, and lower-airway obstruction rather than barking cough and inspiratory stridor."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Foreign body aspiration usually begins suddenly after a choking episode and often causes unilateral decreased breath sounds or localized wheezing."
            },
            {
              "id": "B",
              "text": "Option B: Acute epiglottitis is inappropriate because epiglottitis typically causes abrupt high fever, severe sore throat, drooling, dysphagia, muffled voice, and tripod positioning without a prominent barking cough."
            },
            {
              "id": "C",
              "text": "Option C: Bacterial tracheitis generally causes high fever, toxic appearance, progressive airway obstruction, and thick purulent secretions, often after an initial viral illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Foreign body aspiration usually begins suddenly after a choking episode and often causes unilateral decreased breath sounds or localized wheezing."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Retropharyngeal abscess can cause fever, stridor, and respiratory distress in a young child, but it usually produces sore throat, dysphagia, drooling, neck pain or stiffness, torticollis, or posterior pharyngeal swelling. The normal oropharynx, absence of drooling, and characteristic barking cough favor croup."
            },
            {
              "id": "B",
              "text": "Option B: Acute epiglottitis is inappropriate because epiglottitis typically causes abrupt high fever, severe sore throat, drooling, dysphagia, muffled voice, and tripod positioning without a prominent barking cough."
            },
            {
              "id": "C",
              "text": "Option C: Bacterial tracheitis generally causes high fever, toxic appearance, progressive airway obstruction, and thick purulent secretions, often after an initial viral illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Retropharyngeal abscess can cause fever, stridor, and respiratory distress in a young child, but it usually produces sore throat, dysphagia, drooling, neck pain or stiffness, torticollis, or posterior pharyngeal swelling. The normal oropharynx, absence of drooling, and characteristic barking cough favor croup."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anaphylaxis with upper-airway edema is inappropriate because anaphylactic upper-airway edema can cause abrupt stridor and respiratory distress, but it ordinarily follows an allergen exposure and is accompanied by features such as facial or tongue swelling, urticaria, wheezing, or hemodynamic compromise. This child\u0027s febrile viral prodrome followed by a barking cough is characteristic of infectious croup."
            },
            {
              "id": "B",
              "text": "Option B: Acute epiglottitis is inappropriate because epiglottitis typically causes abrupt high fever, severe sore throat, drooling, dysphagia, muffled voice, and tripod positioning without a prominent barking cough."
            },
            {
              "id": "C",
              "text": "Option C: Bacterial tracheitis generally causes high fever, toxic appearance, progressive airway obstruction, and thick purulent secretions, often after an initial viral illness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anaphylaxis with upper-airway edema is inappropriate because anaphylactic upper-airway edema can cause abrupt stridor and respiratory distress, but it ordinarily follows an allergen exposure and is accompanied by features such as facial or tongue swelling, urticaria, wheezing, or hemodynamic compromise. This child\u0027s febrile viral prodrome followed by a barking cough is characteristic of infectious croup."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-hypertrophic-pyloric-stenosis-1604",
      "expectedHashes": {
        "ranaze_step3_uat": "59bd3ffc13e4d9f90795cd089998804c18599f3e740185b9d82045f2913b4413",
        "ranaze_step3_prd": "59bd3ffc13e4d9f90795cd089998804c18599f3e740185b9d82045f2913b4413"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cow\u0027s milk protein allergy more often causes blood-streaked stools, diarrhea, eczema, or irritability rather than projectile vomiting with an epigastric mass."
            },
            {
              "id": "B",
              "text": "Option C: Physiologic gastroesophageal reflux causes effortless regurgitation in an otherwise thriving infant and does not produce dehydration, weight loss, visible peristalsis, or a palpable mass."
            },
            {
              "id": "C",
              "text": "Option D: Malrotation with midgut volvulus is inappropriate because midgut volvulus usually causes bilious vomiting and may be accompanied by abdominal distention, tenderness, or rapid clinical deterioration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cow\u0027s milk protein allergy more often causes blood-streaked stools, diarrhea, eczema, or irritability rather than projectile vomiting with an epigastric mass."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Physiologic gastroesophageal reflux causes effortless regurgitation in an otherwise thriving infant and does not produce dehydration, weight loss, visible peristalsis, or a palpable mass."
            },
            {
              "id": "B",
              "text": "Option B: Cow\u0027s milk protein allergy more often causes blood-streaked stools, diarrhea, eczema, or irritability rather than projectile vomiting with an epigastric mass."
            },
            {
              "id": "C",
              "text": "Option D: Malrotation with midgut volvulus is inappropriate because midgut volvulus usually causes bilious vomiting and may be accompanied by abdominal distention, tenderness, or rapid clinical deterioration."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Physiologic gastroesophageal reflux causes effortless regurgitation in an otherwise thriving infant and does not produce dehydration, weight loss, visible peristalsis, or a palpable mass."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Malrotation with midgut volvulus is inappropriate because midgut volvulus usually causes bilious vomiting and may be accompanied by abdominal distention, tenderness, or rapid clinical deterioration."
            },
            {
              "id": "B",
              "text": "Option B: Cow\u0027s milk protein allergy more often causes blood-streaked stools, diarrhea, eczema, or irritability rather than projectile vomiting with an epigastric mass."
            },
            {
              "id": "C",
              "text": "Option C: Physiologic gastroesophageal reflux causes effortless regurgitation in an otherwise thriving infant and does not produce dehydration, weight loss, visible peristalsis, or a palpable mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Malrotation with midgut volvulus is inappropriate because midgut volvulus usually causes bilious vomiting and may be accompanied by abdominal distention, tenderness, or rapid clinical deterioration."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Viral gastroenteritis commonly causes diarrhea, fever, and acute vomiting rather than a progressive pattern over 10 days with characteristic abdominal findings."
            },
            {
              "id": "B",
              "text": "Option B: Cow\u0027s milk protein allergy more often causes blood-streaked stools, diarrhea, eczema, or irritability rather than projectile vomiting with an epigastric mass."
            },
            {
              "id": "C",
              "text": "Option C: Physiologic gastroesophageal reflux causes effortless regurgitation in an otherwise thriving infant and does not produce dehydration, weight loss, visible peristalsis, or a palpable mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Viral gastroenteritis commonly causes diarrhea, fever, and acute vomiting rather than a progressive pattern over 10 days with characteristic abdominal findings."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pylorospasm can transiently delay gastric emptying and mimic pyloric stenosis on symptoms or imaging, but it does not explain this classic combination of progressive projectile vomiting, visible left-to-right peristalsis, and a firm mobile pyloric mass."
            },
            {
              "id": "B",
              "text": "Option B: Cow\u0027s milk protein allergy more often causes blood-streaked stools, diarrhea, eczema, or irritability rather than projectile vomiting with an epigastric mass."
            },
            {
              "id": "C",
              "text": "Option C: Physiologic gastroesophageal reflux causes effortless regurgitation in an otherwise thriving infant and does not produce dehydration, weight loss, visible peristalsis, or a palpable mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pylorospasm can transiently delay gastric emptying and mimic pyloric stenosis on symptoms or imaging, but it does not explain this classic combination of progressive projectile vomiting, visible left-to-right peristalsis, and a firm mobile pyloric mass."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intussusception usually affects older infants and causes episodic pain, lethargy, and sometimes bloody stool. It does not produce this feeding-linked progressive pattern and small mobile epigastric pyloric mass."
            },
            {
              "id": "B",
              "text": "Option B: Cow\u0027s milk protein allergy more often causes blood-streaked stools, diarrhea, eczema, or irritability rather than projectile vomiting with an epigastric mass."
            },
            {
              "id": "C",
              "text": "Option C: Physiologic gastroesophageal reflux causes effortless regurgitation in an otherwise thriving infant and does not produce dehydration, weight loss, visible peristalsis, or a palpable mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intussusception usually affects older infants and causes episodic pain, lethargy, and sometimes bloody stool. It does not produce this feeding-linked progressive pattern and small mobile epigastric pyloric mass."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-physiologic-anemia-infancy-940",
      "expectedHashes": {
        "ranaze_step3_uat": "d724a5f2f82ba98233a5e2aef733c7c721d655ce85940143be1eb2fcceba4cd5",
        "ranaze_step3_prd": "d724a5f2f82ba98233a5e2aef733c7c721d655ce85940143be1eb2fcceba4cd5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "B",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            },
            {
              "id": "C",
              "text": "Option D: It should remain near the current value throughout childhood is inappropriate because the hematocrit does not remain fixed; it normally falls after birth and later rises."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option D: It should remain near the current value throughout childhood is inappropriate because the hematocrit does not remain fixed; it normally falls after birth and later rises."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It should remain near the current value throughout childhood is inappropriate because the hematocrit does not remain fixed; it normally falls after birth and later rises."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It should remain near the current value throughout childhood is inappropriate because the hematocrit does not remain fixed; it normally falls after birth and later rises."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It will rise above the birth value during the next month is inappropriate because the hematocrit is not expected to exceed the neonatal birth value during the next month."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It will rise above the birth value during the next month is inappropriate because the hematocrit is not expected to exceed the neonatal birth value during the next month."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It will reach its lowest value within the next 1-2 weeks and then begin to rise is inappropriate because a term infant\u0027s physiologic hemoglobin and hematocrit nadir generally occurs at approximately 2-3 months, not at 4-5 weeks. Recovery begins only after the physiologic nadir."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It will reach its lowest value within the next 1-2 weeks and then begin to rise is inappropriate because a term infant\u0027s physiologic hemoglobin and hematocrit nadir generally occurs at approximately 2-3 months, not at 4-5 weeks. Recovery begins only after the physiologic nadir."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It will remain near 43% until 2-3 months of age and then begin to decline is inappropriate because the postnatal decline is already occurring and continues through the first 2-3 months. It does not pause at the current value and begin only later."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It will remain near 43% until 2-3 months of age and then begin to decline is inappropriate because the postnatal decline is already occurring and continues through the first 2-3 months. It does not pause at the current value and begin only later."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It will continue to decline until approximately 6 months of age and then begin to rise is inappropriate because six months is too late for the physiologic nadir in a healthy term infant. Hemoglobin generally reaches its nadir at 2-3 months, remains relatively stable briefly, and rises during months 4-6."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It will continue to decline until approximately 6 months of age and then begin to rise is inappropriate because six months is too late for the physiologic nadir in a healthy term infant. Hemoglobin generally reaches its nadir at 2-3 months, remains relatively stable briefly, and rises during months 4-6."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "It will continue to decline unless prophylactic iron supplementation is started now is inappropriate because physiologic anemia of infancy is caused by postnatal erythropoietin suppression and shorter neonatal erythrocyte survival, not iron deficiency. This normal, asymptomatic course does not require iron treatment to reverse it."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "It will continue to decline unless prophylactic iron supplementation is started now is inappropriate because physiologic anemia of infancy is caused by postnatal erythropoietin suppression and shorter neonatal erythrocyte survival, not iron deficiency. This normal, asymptomatic course does not require iron treatment to reverse it."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Because he is formula-fed, it should remain near 43% during the next several weeks is inappropriate because formula feeding does not prevent physiologic anemia of infancy. The infant\u0027s hematocrit has already fallen despite exclusive formula feeding."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Because he is formula-fed, it should remain near 43% during the next several weeks is inappropriate because formula feeding does not prevent physiologic anemia of infancy. The infant\u0027s hematocrit has already fallen despite exclusive formula feeding."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The decrease from 52% to 43% indicates occult blood loss, so it will continue to fall without treatment is inappropriate because the observed decline is expected in a healthy term infant. Occult or acute blood loss would require supporting clinical evidence; this infant has no bleeding, pallor, feeding difficulty, respiratory symptoms, or abnormal examination findings."
            },
            {
              "id": "B",
              "text": "Option B: It has already reached its lowest expected value and should rise immediately is inappropriate because at 3 weeks of age, a term infant generally has not yet reached the physiologic hematocrit nadir."
            },
            {
              "id": "C",
              "text": "Option C: It will continue to decline progressively until adolescence is inappropriate because the decline is temporary and does not continue through childhood or adolescence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The decrease from 52% to 43% indicates occult blood loss, so it will continue to fall without treatment is inappropriate because the observed decline is expected in a healthy term infant. Occult or acute blood loss would require supporting clinical evidence; this infant has no bleeding, pallor, feeding difficulty, respiratory symptoms, or abnormal examination findings."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-sports-clearance-innocent-murmur-1427",
      "expectedHashes": {
        "ranaze_step3_uat": "d41a0306afe63c47888084a9fecfc45dc56d7328a3671ded51e451df01550ff5",
        "ranaze_step3_prd": "d41a0306afe63c47888084a9fecfc45dc56d7328a3671ded51e451df01550ff5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "B",
              "text": "Option C: Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            },
            {
              "id": "C",
              "text": "Option D: Exclude her from contact sports because of the prior febrile seizure is inappropriate because a single remote febrile seizure does not indicate epilepsy and does not disqualify a child from contact sports."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            },
            {
              "id": "B",
              "text": "Option B: Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "C",
              "text": "Option D: Exclude her from contact sports because of the prior febrile seizure is inappropriate because a single remote febrile seizure does not indicate epilepsy and does not disqualify a child from contact sports."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exclude her from contact sports because of the prior febrile seizure is inappropriate because a single remote febrile seizure does not indicate epilepsy and does not disqualify a child from contact sports."
            },
            {
              "id": "B",
              "text": "Option B: Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "C",
              "text": "Option C: Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exclude her from contact sports because of the prior febrile seizure is inappropriate because a single remote febrile seizure does not indicate epilepsy and does not disqualify a child from contact sports."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Restrict her to low-intensity activities because of asthma is inappropriate because children with controlled asthma should be encouraged to exercise rather than restricted to low-intensity activity."
            },
            {
              "id": "B",
              "text": "Option B: Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "C",
              "text": "Option C: Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Restrict her to low-intensity activities because of asthma is inappropriate because children with controlled asthma should be encouraged to exercise rather than restricted to low-intensity activity."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a screening electrocardiogram before allowing participation is inappropriate because routine ECG screening is not recommended for an asymptomatic young athlete with a reassuring family history and benign examination. The murmur\u2019s disappearance on standing strongly supports an innocent murmur."
            },
            {
              "id": "B",
              "text": "Option B: Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "C",
              "text": "Option C: Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a screening electrocardiogram before allowing participation is inappropriate because routine ECG screening is not recommended for an asymptomatic young athlete with a reassuring family history and benign examination. The murmur\u2019s disappearance on standing strongly supports an innocent murmur."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an exercise stress test before allowing participation is inappropriate because exercise stress testing is reserved for concerning symptoms or cardiovascular findings. She has no exertional chest pain, syncope, or palpitations and has a benign dynamic murmur."
            },
            {
              "id": "B",
              "text": "Option B: Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "C",
              "text": "Option C: Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an exercise stress test before allowing participation is inappropriate because exercise stress testing is reserved for concerning symptoms or cardiovascular findings. She has no exertional chest pain, syncope, or palpitations and has a benign dynamic murmur."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer clearance pending consultation with a pediatric cardiologist is inappropriate because cardiology referral is appropriate for a pathologic-sounding murmur, cardiac symptoms, or concerning family history. None is present, and an innocent-sounding murmur does not require referral before clearance."
            },
            {
              "id": "B",
              "text": "Option B: Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "C",
              "text": "Option C: Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer clearance pending consultation with a pediatric cardiologist is inappropriate because cardiology referral is appropriate for a pathologic-sounding murmur, cardiac symptoms, or concerning family history. None is present, and an innocent-sounding murmur does not require referral before clearance."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Defer clearance pending consultation with a pediatric neurologist is inappropriate because neurologic clearance is not required for a remote febrile seizure without recurrence or developmental abnormality. Even many patients with controlled epilepsy can participate in sports."
            },
            {
              "id": "B",
              "text": "Option B: Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "C",
              "text": "Option C: Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Defer clearance pending consultation with a pediatric neurologist is inappropriate because neurologic clearance is not required for a remote febrile seizure without recurrence or developmental abnormality. Even many patients with controlled epilepsy can participate in sports."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Require initiation of a daily inhaled corticosteroid before participation is inappropriate because her asthma treatment can be reviewed separately under current asthma guidance, but starting a controller is not a prerequisite to sports participation. She has infrequent rescue-inhaler use, no severe exacerbation history, no exercise symptoms, and a normal lung examination."
            },
            {
              "id": "B",
              "text": "Option B: Obtain echocardiography before allowing participation is inappropriate because echocardiography is not indicated for a soft systolic murmur that disappears with standing in an asymptomatic child without a family history of sudden cardiac death."
            },
            {
              "id": "C",
              "text": "Option C: Obtain pulmonary function testing before allowing participation is inappropriate because routine pulmonary function testing is unnecessary solely for sports clearance when established asthma is mild, symptoms are well controlled, and the examination is normal."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Require initiation of a daily inhaled corticosteroid before participation is inappropriate because her asthma treatment can be reviewed separately under current asthma guidance, but starting a controller is not a prerequisite to sports participation. She has infrequent rescue-inhaler use, no severe exacerbation history, no exercise symptoms, and a normal lung examination."
        }
      }
    },
    {
      "externalId": "step3-pediatrics-transposition-great-arteries-3461",
      "expectedHashes": {
        "ranaze_step3_uat": "541d7399ff77ee45126efe57cc136cb74efabeed6e1a3164230cd192483ba0e5",
        "ranaze_step3_prd": "541d7399ff77ee45126efe57cc136cb74efabeed6e1a3164230cd192483ba0e5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "B",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            },
            {
              "id": "C",
              "text": "Option D: An isolated ventricular septal defect produces a left-to-right shunt after pulmonary vascular resistance falls and generally does not cause severe cyanosis in the first hours of life."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option D: An isolated ventricular septal defect produces a left-to-right shunt after pulmonary vascular resistance falls and generally does not cause severe cyanosis in the first hours of life."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An isolated ventricular septal defect produces a left-to-right shunt after pulmonary vascular resistance falls and generally does not cause severe cyanosis in the first hours of life."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An isolated ventricular septal defect produces a left-to-right shunt after pulmonary vascular resistance falls and generally does not cause severe cyanosis in the first hours of life."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A patent ductus arteriosus generally does not independently cause profound central cyanosis and can provide essential mixing in transposition."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A patent ductus arteriosus generally does not independently cause profound central cyanosis and can provide essential mixing in transposition."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Total anomalous pulmonary venous return can cause neonatal cyanosis, particularly when obstructed, but typically produces pulmonary venous congestion or edema rather than the narrow upper mediastinum with pulmonary plethora characteristic of transposition."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Total anomalous pulmonary venous return can cause neonatal cyanosis, particularly when obstructed, but typically produces pulmonary venous congestion or edema rather than the narrow upper mediastinum with pulmonary plethora characteristic of transposition."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Persistent truncus arteriosus allows complete mixing and often causes pulmonary overcirculation, but usually does not produce profound cyanosis within hours of birth. The narrow superior mediastinum and otherwise quiet examination favor transposition."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Persistent truncus arteriosus allows complete mixing and often causes pulmonary overcirculation, but usually does not produce profound cyanosis within hours of birth. The narrow superior mediastinum and otherwise quiet examination favor transposition."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Classic tricuspid atresia generally causes reduced pulmonary blood flow and left-ventricular dominance on ECG. This newborn instead has increased pulmonary markings and age-appropriate right-ventricular dominance."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Classic tricuspid atresia generally causes reduced pulmonary blood flow and left-ventricular dominance on ECG. This newborn instead has increased pulmonary markings and age-appropriate right-ventricular dominance."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary atresia with intact ventricular septum is inappropriate because pulmonary atresia causes severe ductal-dependent cyanosis but markedly reduces pulmonary blood flow. The increased pulmonary vascular markings in this infant argue against pulmonary atresia."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary atresia with intact ventricular septum is inappropriate because pulmonary atresia causes severe ductal-dependent cyanosis but markedly reduces pulmonary blood flow. The increased pulmonary vascular markings in this infant argue against pulmonary atresia."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Severe Ebstein anomaly can cause neonatal cyanosis but commonly produces striking cardiomegaly from right-atrial enlargement and reduced effective pulmonary flow. A narrow mediastinum with increased pulmonary markings is not its characteristic radiographic pattern."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Severe Ebstein anomaly can cause neonatal cyanosis but commonly produces striking cardiomegaly from right-atrial enlargement and reduced effective pulmonary flow. A narrow mediastinum with increased pulmonary markings is not its characteristic radiographic pattern."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Neonatal respiratory distress syndrome is inappropriate because respiratory distress syndrome is mainly a disease of prematurity and causes diffuse low-volume granular lung disease. This term infant has a cardiac radiographic pattern and profound hypoxemia minimally responsive to oxygen."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Neonatal respiratory distress syndrome is inappropriate because respiratory distress syndrome is mainly a disease of prematurity and causes diffuse low-volume granular lung disease. This term infant has a cardiac radiographic pattern and profound hypoxemia minimally responsive to oxygen."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transient tachypnea of the newborn is inappropriate because transient tachypnea may occur in term newborns and can show prominent pulmonary markings, but it causes respiratory distress with hypoxemia that is generally much less profound and responsive to supplemental oxygen. It does not explain a narrow superior mediastinum and single loud S2."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transient tachypnea of the newborn is inappropriate because transient tachypnea may occur in term newborns and can show prominent pulmonary markings, but it causes respiratory distress with hypoxemia that is generally much less profound and responsive to supplemental oxygen. It does not explain a narrow superior mediastinum and single loud S2."
        },
        "M": {
          "prompt": "Which feature of option M should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Methemoglobinemia can cause cyanosis with limited improvement from oxygen, but it does not cause pulmonary vascular plethora, a narrow superior mediastinum, or a single loud S2. No oxidant exposure is provided."
            },
            {
              "id": "B",
              "text": "Option B: Persistent pulmonary hypertension of the newborn is inappropriate because persistent pulmonary hypertension can cause neonatal hypoxemia but does not produce the characteristic narrow mediastinal contour with pulmonary plethora."
            },
            {
              "id": "C",
              "text": "Option C: Tetralogy of Fallot generally reduces pulmonary blood flow, producing diminished rather than increased pulmonary vascular markings."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Methemoglobinemia can cause cyanosis with limited improvement from oxygen, but it does not cause pulmonary vascular plethora, a narrow superior mediastinum, or a single loud S2. No oxidant exposure is provided."
        }
      }
    },
    {
      "externalId": "step3-peds-lead-001",
      "expectedHashes": {
        "ranaze_step3_uat": "488c07a2dca1947de4d569f040f6cdb69ebfc2eb166ab92002ae36ffe287d3d6",
        "ranaze_step3_prd": "488c07a2dca1947de4d569f040f6cdb69ebfc2eb166ab92002ae36ffe287d3d6"
      },
      "replacement": {
        "A": {
          "prompt": "Which feature of option A should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
            },
            {
              "id": "B",
              "text": "Option C: Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
            },
            {
              "id": "C",
              "text": "Option D: Iron supplementation alone with routine outpatient follow-up is inappropriate because iron deficiency should be treated if present, but it is not sufficient management for this blood lead level."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
            },
            {
              "id": "B",
              "text": "Option A: Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
            },
            {
              "id": "C",
              "text": "Option D: Iron supplementation alone with routine outpatient follow-up is inappropriate because iron deficiency should be treated if present, but it is not sufficient management for this blood lead level."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Iron supplementation alone with routine outpatient follow-up is inappropriate because iron deficiency should be treated if present, but it is not sufficient management for this blood lead level."
            },
            {
              "id": "B",
              "text": "Option A: Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Iron supplementation alone with routine outpatient follow-up is inappropriate because iron deficiency should be treated if present, but it is not sufficient management for this blood lead level."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Whole-bowel irrigation without chelation therapy is inappropriate because whole-bowel irrigation is considered for retained lead-containing foreign bodies or particles in the gastrointestinal tract, not as sole therapy here."
            },
            {
              "id": "B",
              "text": "Option A: Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Whole-bowel irrigation without chelation therapy is inappropriate because whole-bowel irrigation is considered for retained lead-containing foreign bodies or particles in the gastrointestinal tract, not as sole therapy here."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay treatment until a third venous blood lead level confirms the result is inappropriate because the value of 52 mcg/dL is already a repeat venous measurement. Additional confirmation must not delay toxicology consultation, removal from exposure, and chelation."
            },
            {
              "id": "B",
              "text": "Option A: Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay treatment until a third venous blood lead level confirms the result is inappropriate because the value of 52 mcg/dL is already a repeat venous measurement. Additional confirmation must not delay toxicology consultation, removal from exposure, and chelation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start oral succimer while allowing the child to remain in the home during renovation is inappropriate because chelation should not occur during continued lead exposure because rebound or continued accumulation can occur. The child must be moved to a lead-safe environment while succimer is given."
            },
            {
              "id": "B",
              "text": "Option A: Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start oral succimer while allowing the child to remain in the home during renovation is inappropriate because chelation should not occur during continued lead exposure because rebound or continued accumulation can occur. The child must be moved to a lead-safe environment while succimer is given."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Treat with intravenous deferoxamine is inappropriate because deferoxamine is used primarily for iron toxicity, not lead poisoning. Succimer is the appropriate oral chelator for this confirmed blood lead range without encephalopathy."
            },
            {
              "id": "B",
              "text": "Option A: Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Treat with intravenous deferoxamine is inappropriate because deferoxamine is used primarily for iron toxicity, not lead poisoning. Succimer is the appropriate oral chelator for this confirmed blood lead range without encephalopathy."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain an abdominal radiograph and withhold chelation if no radiopaque material is seen is inappropriate because an abdominal radiograph is recommended at this lead level to look for ingested radiopaque material and guide bowel decontamination, but a negative image does not negate the systemic venous level or the indication for chelation."
            },
            {
              "id": "B",
              "text": "Option A: Reassurance and repeat blood lead level in 12 months is inappropriate because this level is far above the threshold for close follow-up alone."
            },
            {
              "id": "C",
              "text": "Option C: Intramuscular dimercaprol plus intravenous calcium disodium EDTA is inappropriate because this regimen is used for encephalopathy or very high blood lead levels, not a stable child with a level of 52 mcg/dL."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain an abdominal radiograph and withhold chelation if no radiopaque material is seen is inappropriate because an abdominal radiograph is recommended at this lead level to look for ingested radiopaque material and guide bowel decontamination, but a negative image does not negate the systemic venous level or the indication for chelation."
        }
      }
    },
    {
      "externalId": "step3-preventive-care-smoking-cessation-593",
      "expectedHashes": {
        "ranaze_step3_uat": "7e83004dec2c9c821ce869fdca1964584136417ff2e4c0a573211c9bd0cae989",
        "ranaze_step3_prd": "7e83004dec2c9c821ce869fdca1964584136417ff2e4c0a573211c9bd0cae989"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order a serum prostate-specific antigen test is inappropriate because pSA screening is not routinely indicated at age 42 in an average-risk man based only on prostate cancer in an elderly second-degree relative."
            },
            {
              "id": "B",
              "text": "Option C: Schedule screening colonoscopy is inappropriate because average-risk colorectal cancer screening begins at age 45, and colonoscopy is only one of several accepted screening strategies."
            },
            {
              "id": "C",
              "text": "Option D: Order fasting lipid testing solely because of his family history is inappropriate because lipid measurement may be part of cardiovascular risk assessment because of his age and smoking, but his father\u0027s hypertension alone is not the reason stated for testing and smoking cessation is the clearest indicated intervention among the choices."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order a serum prostate-specific antigen test is inappropriate because pSA screening is not routinely indicated at age 42 in an average-risk man based only on prostate cancer in an elderly second-degree relative."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Schedule screening colonoscopy is inappropriate because average-risk colorectal cancer screening begins at age 45, and colonoscopy is only one of several accepted screening strategies."
            },
            {
              "id": "B",
              "text": "Option B: Order a serum prostate-specific antigen test is inappropriate because pSA screening is not routinely indicated at age 42 in an average-risk man based only on prostate cancer in an elderly second-degree relative."
            },
            {
              "id": "C",
              "text": "Option D: Order fasting lipid testing solely because of his family history is inappropriate because lipid measurement may be part of cardiovascular risk assessment because of his age and smoking, but his father\u0027s hypertension alone is not the reason stated for testing and smoking cessation is the clearest indicated intervention among the choices."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Schedule screening colonoscopy is inappropriate because average-risk colorectal cancer screening begins at age 45, and colonoscopy is only one of several accepted screening strategies."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order fasting lipid testing solely because of his family history is inappropriate because lipid measurement may be part of cardiovascular risk assessment because of his age and smoking, but his father\u0027s hypertension alone is not the reason stated for testing and smoking cessation is the clearest indicated intervention among the choices."
            },
            {
              "id": "B",
              "text": "Option B: Order a serum prostate-specific antigen test is inappropriate because pSA screening is not routinely indicated at age 42 in an average-risk man based only on prostate cancer in an elderly second-degree relative."
            },
            {
              "id": "C",
              "text": "Option C: Schedule screening colonoscopy is inappropriate because average-risk colorectal cancer screening begins at age 45, and colonoscopy is only one of several accepted screening strategies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order fasting lipid testing solely because of his family history is inappropriate because lipid measurement may be part of cardiovascular risk assessment because of his age and smoking, but his father\u0027s hypertension alone is not the reason stated for testing and smoking cessation is the clearest indicated intervention among the choices."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recommend weight-loss counseling is inappropriate because his BMI is 23 kg/m2, within the normal range, so weight-loss counseling is not indicated."
            },
            {
              "id": "B",
              "text": "Option B: Order a serum prostate-specific antigen test is inappropriate because pSA screening is not routinely indicated at age 42 in an average-risk man based only on prostate cancer in an elderly second-degree relative."
            },
            {
              "id": "C",
              "text": "Option C: Schedule screening colonoscopy is inappropriate because average-risk colorectal cancer screening begins at age 45, and colonoscopy is only one of several accepted screening strategies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recommend weight-loss counseling is inappropriate because his BMI is 23 kg/m2, within the normal range, so weight-loss counseling is not indicated."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin annual low-dose CT screening for lung cancer is inappropriate because he is only 42 and has approximately 7.2 pack-years of exposure (0.4 pack/day for 18 years). Annual low-dose CT is recommended for adults aged 50-80 with at least 20 pack-years who currently smoke or quit within 15 years."
            },
            {
              "id": "B",
              "text": "Option B: Order a serum prostate-specific antigen test is inappropriate because pSA screening is not routinely indicated at age 42 in an average-risk man based only on prostate cancer in an elderly second-degree relative."
            },
            {
              "id": "C",
              "text": "Option C: Schedule screening colonoscopy is inappropriate because average-risk colorectal cancer screening begins at age 45, and colonoscopy is only one of several accepted screening strategies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin annual low-dose CT screening for lung cancer is inappropriate because he is only 42 and has approximately 7.2 pack-years of exposure (0.4 pack/day for 18 years). Annual low-dose CT is recommended for adults aged 50-80 with at least 20 pack-years who currently smoke or quit within 15 years."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Order one-time abdominal ultrasonography to screen for an aortic aneurysm is inappropriate because smoking is an AAA risk factor, but one-time ultrasonographic screening is recommended for men aged 65-75 who have ever smoked, not a 42-year-old."
            },
            {
              "id": "B",
              "text": "Option B: Order a serum prostate-specific antigen test is inappropriate because pSA screening is not routinely indicated at age 42 in an average-risk man based only on prostate cancer in an elderly second-degree relative."
            },
            {
              "id": "C",
              "text": "Option C: Schedule screening colonoscopy is inappropriate because average-risk colorectal cancer screening begins at age 45, and colonoscopy is only one of several accepted screening strategies."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Order one-time abdominal ultrasonography to screen for an aortic aneurysm is inappropriate because smoking is an AAA risk factor, but one-time ultrasonographic screening is recommended for men aged 65-75 who have ever smoked, not a 42-year-old."
        }
      }
    },
    {
      "externalId": "step3-psychiatry-alcohol-use-disorder-family-history-2736",
      "expectedHashes": {
        "ranaze_step3_uat": "d3926261d3a37bda762dc14afcba69e7df7bd73c50a1cd6779dd3312e9f77569",
        "ranaze_step3_prd": "d3926261d3a37bda762dc14afcba69e7df7bd73c50a1cd6779dd3312e9f77569"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remote treatment for childhood attention-deficit/hyperactivity disorder is inappropriate because childhood ADHD is associated with increased risk of later substance misuse, but it is a less specific predictor than a first-degree family history of alcohol use disorder."
            },
            {
              "id": "B",
              "text": "Option C: Occasional cannabis use is inappropriate because cannabis use may indicate broader substance exposure, but occasional use is not as strong a listed risk factor as having an affected biological parent."
            },
            {
              "id": "C",
              "text": "Option D: Growing up in a single-parent household is inappropriate because living in a single-parent household is not itself a major independent risk factor for alcohol use disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remote treatment for childhood attention-deficit/hyperactivity disorder is inappropriate because childhood ADHD is associated with increased risk of later substance misuse, but it is a less specific predictor than a first-degree family history of alcohol use disorder."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Occasional cannabis use is inappropriate because cannabis use may indicate broader substance exposure, but occasional use is not as strong a listed risk factor as having an affected biological parent."
            },
            {
              "id": "B",
              "text": "Option B: Remote treatment for childhood attention-deficit/hyperactivity disorder is inappropriate because childhood ADHD is associated with increased risk of later substance misuse, but it is a less specific predictor than a first-degree family history of alcohol use disorder."
            },
            {
              "id": "C",
              "text": "Option D: Growing up in a single-parent household is inappropriate because living in a single-parent household is not itself a major independent risk factor for alcohol use disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Occasional cannabis use is inappropriate because cannabis use may indicate broader substance exposure, but occasional use is not as strong a listed risk factor as having an affected biological parent."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Growing up in a single-parent household is inappropriate because living in a single-parent household is not itself a major independent risk factor for alcohol use disorder."
            },
            {
              "id": "B",
              "text": "Option B: Remote treatment for childhood attention-deficit/hyperactivity disorder is inappropriate because childhood ADHD is associated with increased risk of later substance misuse, but it is a less specific predictor than a first-degree family history of alcohol use disorder."
            },
            {
              "id": "C",
              "text": "Option C: Occasional cannabis use is inappropriate because cannabis use may indicate broader substance exposure, but occasional use is not as strong a listed risk factor as having an affected biological parent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Growing up in a single-parent household is inappropriate because living in a single-parent household is not itself a major independent risk factor for alcohol use disorder."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Exposure to verbal conflict during childhood is inappropriate because childhood verbal conflict may contribute to psychological distress, but it is less predictive than a first-degree family history."
            },
            {
              "id": "B",
              "text": "Option B: Remote treatment for childhood attention-deficit/hyperactivity disorder is inappropriate because childhood ADHD is associated with increased risk of later substance misuse, but it is a less specific predictor than a first-degree family history of alcohol use disorder."
            },
            {
              "id": "C",
              "text": "Option C: Occasional cannabis use is inappropriate because cannabis use may indicate broader substance exposure, but occasional use is not as strong a listed risk factor as having an affected biological parent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Exposure to verbal conflict during childhood is inappropriate because childhood verbal conflict may contribute to psychological distress, but it is less predictive than a first-degree family history."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Being male is inappropriate because aUD prevalence is higher among males than females in current US survey data, but sex is a broad demographic association. A first-degree relative with the same disorder is a substantially more specific individual risk factor."
            },
            {
              "id": "B",
              "text": "Option B: Remote treatment for childhood attention-deficit/hyperactivity disorder is inappropriate because childhood ADHD is associated with increased risk of later substance misuse, but it is a less specific predictor than a first-degree family history of alcohol use disorder."
            },
            {
              "id": "C",
              "text": "Option C: Occasional cannabis use is inappropriate because cannabis use may indicate broader substance exposure, but occasional use is not as strong a listed risk factor as having an affected biological parent."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Being male is inappropriate because aUD prevalence is higher among males than females in current US survey data, but sex is a broad demographic association. A first-degree relative with the same disorder is a substantially more specific individual risk factor."
        }
      }
    },
    {
      "externalId": "step3-psychiatry-binge-eating-217",
      "expectedHashes": {
        "ranaze_step3_uat": "a0ee35181737248141d27ba71444400b8e650a1bfe7cb7add381408dc674b505",
        "ranaze_step3_prd": "a0ee35181737248141d27ba71444400b8e650a1bfe7cb7add381408dc674b505"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bulimia nervosa requires recurrent inappropriate compensatory behaviors (eg, self-induced vomiting, laxatives, fasting, excessive exercise), which are absent here."
            },
            {
              "id": "B",
              "text": "Option C: Night eating syndrome involves recurrent eating after the evening meal or after awakening from sleep, rather than discrete binge episodes with loss of control."
            },
            {
              "id": "C",
              "text": "Option D: Avoidant/restrictive food intake disorder is characterized by restrictive eating leading to nutritional deficiency or weight loss without body image disturbance or binge episodes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bulimia nervosa requires recurrent inappropriate compensatory behaviors (eg, self-induced vomiting, laxatives, fasting, excessive exercise), which are absent here."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Night eating syndrome involves recurrent eating after the evening meal or after awakening from sleep, rather than discrete binge episodes with loss of control."
            },
            {
              "id": "B",
              "text": "Option B: Bulimia nervosa requires recurrent inappropriate compensatory behaviors (eg, self-induced vomiting, laxatives, fasting, excessive exercise), which are absent here."
            },
            {
              "id": "C",
              "text": "Option D: Avoidant/restrictive food intake disorder is characterized by restrictive eating leading to nutritional deficiency or weight loss without body image disturbance or binge episodes."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Night eating syndrome involves recurrent eating after the evening meal or after awakening from sleep, rather than discrete binge episodes with loss of control."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Avoidant/restrictive food intake disorder is characterized by restrictive eating leading to nutritional deficiency or weight loss without body image disturbance or binge episodes."
            },
            {
              "id": "B",
              "text": "Option B: Bulimia nervosa requires recurrent inappropriate compensatory behaviors (eg, self-induced vomiting, laxatives, fasting, excessive exercise), which are absent here."
            },
            {
              "id": "C",
              "text": "Option C: Night eating syndrome involves recurrent eating after the evening meal or after awakening from sleep, rather than discrete binge episodes with loss of control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Avoidant/restrictive food intake disorder is characterized by restrictive eating leading to nutritional deficiency or weight loss without body image disturbance or binge episodes."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Other specified feeding or eating disorder is used when symptoms do not fully meet criteria for a specific eating disorder. This patient meets the diagnostic features of binge-eating disorder."
            },
            {
              "id": "B",
              "text": "Option B: Bulimia nervosa requires recurrent inappropriate compensatory behaviors (eg, self-induced vomiting, laxatives, fasting, excessive exercise), which are absent here."
            },
            {
              "id": "C",
              "text": "Option C: Night eating syndrome involves recurrent eating after the evening meal or after awakening from sleep, rather than discrete binge episodes with loss of control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Other specified feeding or eating disorder is used when symptoms do not fully meet criteria for a specific eating disorder. This patient meets the diagnostic features of binge-eating disorder."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anorexia nervosa, binge-eating/purging type is inappropriate because anorexia nervosa requires significantly low body weight and typically involves restriction, with binge-eating or purging behavior defining the subtype. This patient has a BMI of 39 kg/m2 and denies restriction, fasting, vomiting, laxative use, and excessive exercise."
            },
            {
              "id": "B",
              "text": "Option B: Bulimia nervosa requires recurrent inappropriate compensatory behaviors (eg, self-induced vomiting, laxatives, fasting, excessive exercise), which are absent here."
            },
            {
              "id": "C",
              "text": "Option C: Night eating syndrome involves recurrent eating after the evening meal or after awakening from sleep, rather than discrete binge episodes with loss of control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anorexia nervosa, binge-eating/purging type is inappropriate because anorexia nervosa requires significantly low body weight and typically involves restriction, with binge-eating or purging behavior defining the subtype. This patient has a BMI of 39 kg/m2 and denies restriction, fasting, vomiting, laxative use, and excessive exercise."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obesity without a coexisting eating disorder is inappropriate because obesity is present but does not account for her recurrent discrete episodes of objectively large food intake, loss of control, distress, embarrassment, and guilt. Obesity and binge-eating disorder can coexist; obesity alone is not an adequate diagnosis for these symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Bulimia nervosa requires recurrent inappropriate compensatory behaviors (eg, self-induced vomiting, laxatives, fasting, excessive exercise), which are absent here."
            },
            {
              "id": "C",
              "text": "Option C: Night eating syndrome involves recurrent eating after the evening meal or after awakening from sleep, rather than discrete binge episodes with loss of control."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obesity without a coexisting eating disorder is inappropriate because obesity is present but does not account for her recurrent discrete episodes of objectively large food intake, loss of control, distress, embarrassment, and guilt. Obesity and binge-eating disorder can coexist; obesity alone is not an adequate diagnosis for these symptoms."
        }
      }
    },
    {
      "externalId": "step3-psychiatry-conduct-disorder-184",
      "expectedHashes": {
        "ranaze_step3_uat": "b1de49ef997b9a81f36b52ba90c4feb32ab5d22e6120a837417e63d2ee8c15e9",
        "ranaze_step3_prd": "b1de49ef997b9a81f36b52ba90c4feb32ab5d22e6120a837417e63d2ee8c15e9"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Frequent arguments with teachers and parents is inappropriate because frequent arguing with authority figures is typical of oppositional defiant disorder and may also occur in conduct disorder but is not the distinguishing feature."
            },
            {
              "id": "B",
              "text": "Option C: Blaming others for his own misconduct is inappropriate because externalizing blame is commonly seen in oppositional defiant disorder and is not specific for conduct disorder."
            },
            {
              "id": "C",
              "text": "Option D: Persistent irritability and resentment is inappropriate because an irritable mood is a core feature of oppositional defiant disorder and does not distinguish conduct disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Frequent arguments with teachers and parents is inappropriate because frequent arguing with authority figures is typical of oppositional defiant disorder and may also occur in conduct disorder but is not the distinguishing feature."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Blaming others for his own misconduct is inappropriate because externalizing blame is commonly seen in oppositional defiant disorder and is not specific for conduct disorder."
            },
            {
              "id": "B",
              "text": "Option B: Frequent arguments with teachers and parents is inappropriate because frequent arguing with authority figures is typical of oppositional defiant disorder and may also occur in conduct disorder but is not the distinguishing feature."
            },
            {
              "id": "C",
              "text": "Option D: Persistent irritability and resentment is inappropriate because an irritable mood is a core feature of oppositional defiant disorder and does not distinguish conduct disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Blaming others for his own misconduct is inappropriate because externalizing blame is commonly seen in oppositional defiant disorder and is not specific for conduct disorder."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Persistent irritability and resentment is inappropriate because an irritable mood is a core feature of oppositional defiant disorder and does not distinguish conduct disorder."
            },
            {
              "id": "B",
              "text": "Option B: Frequent arguments with teachers and parents is inappropriate because frequent arguing with authority figures is typical of oppositional defiant disorder and may also occur in conduct disorder but is not the distinguishing feature."
            },
            {
              "id": "C",
              "text": "Option C: Blaming others for his own misconduct is inappropriate because externalizing blame is commonly seen in oppositional defiant disorder and is not specific for conduct disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Persistent irritability and resentment is inappropriate because an irritable mood is a core feature of oppositional defiant disorder and does not distinguish conduct disorder."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Symptoms occurring at home, school, and camp is inappropriate because impairment across multiple settings supports the presence of a behavioral disorder but does not differentiate conduct disorder from oppositional defiant disorder."
            },
            {
              "id": "B",
              "text": "Option B: Frequent arguments with teachers and parents is inappropriate because frequent arguing with authority figures is typical of oppositional defiant disorder and may also occur in conduct disorder but is not the distinguishing feature."
            },
            {
              "id": "C",
              "text": "Option C: Blaming others for his own misconduct is inappropriate because externalizing blame is commonly seen in oppositional defiant disorder and is not specific for conduct disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Symptoms occurring at home, school, and camp is inappropriate because impairment across multiple settings supports the presence of a behavioral disorder but does not differentiate conduct disorder from oppositional defiant disorder."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "The disruptive behavior has persisted for approximately one year is inappropriate because a one-year course is compatible with conduct disorder, but duration alone does not distinguish it from oppositional defiant disorder, which also requires a persistent pattern. The differentiating feature is severe violation of others\u0027 rights or major norms through assault, intimidation, breaking and entering, theft, and property destruction."
            },
            {
              "id": "B",
              "text": "Option B: Frequent arguments with teachers and parents is inappropriate because frequent arguing with authority figures is typical of oppositional defiant disorder and may also occur in conduct disorder but is not the distinguishing feature."
            },
            {
              "id": "C",
              "text": "Option C: Blaming others for his own misconduct is inappropriate because externalizing blame is commonly seen in oppositional defiant disorder and is not specific for conduct disorder."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "The disruptive behavior has persisted for approximately one year is inappropriate because a one-year course is compatible with conduct disorder, but duration alone does not distinguish it from oppositional defiant disorder, which also requires a persistent pattern. The differentiating feature is severe violation of others\u0027 rights or major norms through assault, intimidation, breaking and entering, theft, and property destruction."
        }
      }
    },
    {
      "externalId": "step3-psychiatry-olanzapine-metabolic-monitoring-1284",
      "expectedHashes": {
        "ranaze_step3_uat": "fb12ec6c389b861d0b3c606fc797b76e4c00e014ee994f3c2349ca82265d53ec",
        "ranaze_step3_prd": "fb12ec6c389b861d0b3c606fc797b76e4c00e014ee994f3c2349ca82265d53ec"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "B",
              "text": "Option C: Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            },
            {
              "id": "C",
              "text": "Option D: Brain MRI is inappropriate because brain imaging is not indicated in a psychiatrically stable patient with a normal neurologic examination and a clear medication-related explanation for her symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            },
            {
              "id": "B",
              "text": "Option B: Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "C",
              "text": "Option D: Brain MRI is inappropriate because brain imaging is not indicated in a psychiatrically stable patient with a normal neurologic examination and a clear medication-related explanation for her symptoms."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Brain MRI is inappropriate because brain imaging is not indicated in a psychiatrically stable patient with a normal neurologic examination and a clear medication-related explanation for her symptoms."
            },
            {
              "id": "B",
              "text": "Option B: Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "C",
              "text": "Option C: Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Brain MRI is inappropriate because brain imaging is not indicated in a psychiatrically stable patient with a normal neurologic examination and a clear medication-related explanation for her symptoms."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Formal personality testing is inappropriate because personality testing does not evaluate the metabolic adverse effects of olanzapine."
            },
            {
              "id": "B",
              "text": "Option B: Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "C",
              "text": "Option C: Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Formal personality testing is inappropriate because personality testing does not evaluate the metabolic adverse effects of olanzapine."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Complete blood count with absolute neutrophil count is inappropriate because routine CBC or ANC surveillance is associated principally with clozapine. For olanzapine, frequent CBC monitoring is reserved for patients with a history of clinically significant leukopenia or drug-induced neutropenia; nothing in this stem suggests that complication."
            },
            {
              "id": "B",
              "text": "Option B: Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "C",
              "text": "Option C: Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Complete blood count with absolute neutrophil count is inappropriate because routine CBC or ANC surveillance is associated principally with clozapine. For olanzapine, frequent CBC monitoring is reserved for patients with a history of clinically significant leukopenia or drug-induced neutropenia; nothing in this stem suggests that complication."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Serum prolactin measurement is inappropriate because olanzapine can elevate prolactin, but prolactin measurement would address reproductive or sexual symptoms rather than the rapid weight gain, increased appetite, prediabetes, and other metabolic risk factors presented here."
            },
            {
              "id": "B",
              "text": "Option B: Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "C",
              "text": "Option C: Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Serum prolactin measurement is inappropriate because olanzapine can elevate prolactin, but prolactin measurement would address reproductive or sexual symptoms rather than the rapid weight gain, increased appetite, prediabetes, and other metabolic risk factors presented here."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Thyroid-stimulating hormone measurement is inappropriate because hypothyroidism can cause weight gain, but the marked increase in appetite beginning after olanzapine initiation and the patient\u0027s substantial baseline diabetes risk point to medication-associated dysglycemia rather than thyroid disease."
            },
            {
              "id": "B",
              "text": "Option B: Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "C",
              "text": "Option C: Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Thyroid-stimulating hormone measurement is inappropriate because hypothyroidism can cause weight gain, but the marked increase in appetite beginning after olanzapine initiation and the patient\u0027s substantial baseline diabetes risk point to medication-associated dysglycemia rather than thyroid disease."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urinalysis for glucose and ketones is inappropriate because urine glucose is insensitive for screening or diagnosing diabetes, and ketone testing is intended for suspected metabolic decompensation. Diabetes screening and diagnosis should use validated plasma glucose or A1c criteria."
            },
            {
              "id": "B",
              "text": "Option B: Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "C",
              "text": "Option C: Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urinalysis for glucose and ketones is inappropriate because urine glucose is insensitive for screening or diagnosing diabetes, and ketone testing is intended for suspected metabolic decompensation. Diabetes screening and diagnosis should use validated plasma glucose or A1c criteria."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Overnight dexamethasone suppression test is inappropriate because cushing syndrome testing is reserved for patients with multiple progressive or discriminatory features of cortisol excess. Here, the temporal relationship to olanzapine, increased appetite, and otherwise normal examination provide a direct medication-related explanation."
            },
            {
              "id": "B",
              "text": "Option B: Routine measurement of serum olanzapine concentrations is not recommended because dosing is guided clinically rather than by a therapeutic drug level."
            },
            {
              "id": "C",
              "text": "Option C: Polysomnography is indicated for suspected sleep apnea or another sleep disorder, not medication-associated weight gain and increased appetite alone."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Overnight dexamethasone suppression test is inappropriate because cushing syndrome testing is reserved for patients with multiple progressive or discriminatory features of cortisol excess. Here, the temporal relationship to olanzapine, increased appetite, and otherwise normal examination provide a direct medication-related explanation."
        }
      }
    },
    {
      "externalId": "step3-pulmonary-endobronchial-obstruction-5714",
      "expectedHashes": {
        "ranaze_step3_uat": "ac7742ef5a44cd6a5aeba8d37fc1c0bc935a40f48edf34b3319d483715159e3a"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Primary ciliary dyskinesia causes diffuse recurrent sinopulmonary infections, chronic sinusitis, and sometimes laterality abnormalities rather than repeated infection confined to one lobe."
            },
            {
              "id": "B",
              "text": "Option C: Chronic aspiration due to gastroesophageal reflux is inappropriate because chronic aspiration usually affects dependent regions more diffusely and is generally associated with swallowing dysfunction, neurologic disease, or reflux symptoms rather than fixed disease after a choking event."
            },
            {
              "id": "C",
              "text": "Option D: Common variable immunodeficiency causes recurrent infections involving multiple pulmonary locations and other sinopulmonary sites, not isolated disease in one segment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Primary ciliary dyskinesia causes diffuse recurrent sinopulmonary infections, chronic sinusitis, and sometimes laterality abnormalities rather than repeated infection confined to one lobe."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic aspiration due to gastroesophageal reflux is inappropriate because chronic aspiration usually affects dependent regions more diffusely and is generally associated with swallowing dysfunction, neurologic disease, or reflux symptoms rather than fixed disease after a choking event."
            },
            {
              "id": "B",
              "text": "Option B: Primary ciliary dyskinesia causes diffuse recurrent sinopulmonary infections, chronic sinusitis, and sometimes laterality abnormalities rather than repeated infection confined to one lobe."
            },
            {
              "id": "C",
              "text": "Option D: Common variable immunodeficiency causes recurrent infections involving multiple pulmonary locations and other sinopulmonary sites, not isolated disease in one segment."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic aspiration due to gastroesophageal reflux is inappropriate because chronic aspiration usually affects dependent regions more diffusely and is generally associated with swallowing dysfunction, neurologic disease, or reflux symptoms rather than fixed disease after a choking event."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Common variable immunodeficiency causes recurrent infections involving multiple pulmonary locations and other sinopulmonary sites, not isolated disease in one segment."
            },
            {
              "id": "B",
              "text": "Option B: Primary ciliary dyskinesia causes diffuse recurrent sinopulmonary infections, chronic sinusitis, and sometimes laterality abnormalities rather than repeated infection confined to one lobe."
            },
            {
              "id": "C",
              "text": "Option C: Chronic aspiration due to gastroesophageal reflux is inappropriate because chronic aspiration usually affects dependent regions more diffusely and is generally associated with swallowing dysfunction, neurologic disease, or reflux symptoms rather than fixed disease after a choking event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Common variable immunodeficiency causes recurrent infections involving multiple pulmonary locations and other sinopulmonary sites, not isolated disease in one segment."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cystic fibrosis causes chronic respiratory disease involving multiple regions and often poor growth or pancreatic insufficiency."
            },
            {
              "id": "B",
              "text": "Option B: Primary ciliary dyskinesia causes diffuse recurrent sinopulmonary infections, chronic sinusitis, and sometimes laterality abnormalities rather than repeated infection confined to one lobe."
            },
            {
              "id": "C",
              "text": "Option C: Chronic aspiration due to gastroesophageal reflux is inappropriate because chronic aspiration usually affects dependent regions more diffusely and is generally associated with swallowing dysfunction, neurologic disease, or reflux symptoms rather than fixed disease after a choking event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cystic fibrosis causes chronic respiratory disease involving multiple regions and often poor growth or pancreatic insufficiency."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Endobronchial carcinoid tumor is inappropriate because an endobronchial carcinoid can obstruct a bronchus and cause recurrent pneumonia in one lobe, but it is much rarer in a 6-year-old and does not fit the strong temporal clue of choking on nuts before the recurrent infections began."
            },
            {
              "id": "B",
              "text": "Option B: Primary ciliary dyskinesia causes diffuse recurrent sinopulmonary infections, chronic sinusitis, and sometimes laterality abnormalities rather than repeated infection confined to one lobe."
            },
            {
              "id": "C",
              "text": "Option C: Chronic aspiration due to gastroesophageal reflux is inappropriate because chronic aspiration usually affects dependent regions more diffusely and is generally associated with swallowing dysfunction, neurologic disease, or reflux symptoms rather than fixed disease after a choking event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Endobronchial carcinoid tumor is inappropriate because an endobronchial carcinoid can obstruct a bronchus and cause recurrent pneumonia in one lobe, but it is much rarer in a 6-year-old and does not fit the strong temporal clue of choking on nuts before the recurrent infections began."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Asthma with recurrent mucus plugging is inappropriate because asthma can cause wheezing and mucus plugging, but it generally causes recurrent or diffuse symptoms rather than pneumonia repeatedly confined to one lobe. The child is asymptomatic between infections and had a preceding choking event."
            },
            {
              "id": "B",
              "text": "Option B: Primary ciliary dyskinesia causes diffuse recurrent sinopulmonary infections, chronic sinusitis, and sometimes laterality abnormalities rather than repeated infection confined to one lobe."
            },
            {
              "id": "C",
              "text": "Option C: Chronic aspiration due to gastroesophageal reflux is inappropriate because chronic aspiration usually affects dependent regions more diffusely and is generally associated with swallowing dysfunction, neurologic disease, or reflux symptoms rather than fixed disease after a choking event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Asthma with recurrent mucus plugging is inappropriate because asthma can cause wheezing and mucus plugging, but it generally causes recurrent or diffuse symptoms rather than pneumonia repeatedly confined to one lobe. The child is asymptomatic between infections and had a preceding choking event."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Congenital pulmonary airway malformation is a localized developmental lung lesion that can present in an older child with recurrent pulmonary infection, so it is a plausible focal-malformation alternative. In this stem, however, the recurrent disease began after a discrete choking episode involving nuts and is accompanied by focal wheezing and persistent volume loss in the same region. That chronology and obstructive pattern specifically indicate a retained endobronchial foreign body; no cystic lung lesion is described."
            },
            {
              "id": "B",
              "text": "Option B: Primary ciliary dyskinesia causes diffuse recurrent sinopulmonary infections, chronic sinusitis, and sometimes laterality abnormalities rather than repeated infection confined to one lobe."
            },
            {
              "id": "C",
              "text": "Option C: Chronic aspiration due to gastroesophageal reflux is inappropriate because chronic aspiration usually affects dependent regions more diffusely and is generally associated with swallowing dysfunction, neurologic disease, or reflux symptoms rather than fixed disease after a choking event."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Congenital pulmonary airway malformation is a localized developmental lung lesion that can present in an older child with recurrent pulmonary infection, so it is a plausible focal-malformation alternative. In this stem, however, the recurrent disease began after a discrete choking episode involving nuts and is accompanied by focal wheezing and persistent volume loss in the same region. That chronology and obstructive pattern specifically indicate a retained endobronchial foreign body; no cystic lung lesion is described."
        }
      }
    },
    {
      "externalId": "step3-pulmonary-lung-cancer-chest-ct-631",
      "expectedHashes": {
        "ranaze_step3_uat": "e7541e0cba8ee41286c8208ac3cbdd0185bece7e1c1c9c90bce39412e6a2be0c"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "B",
              "text": "Option C: CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            },
            {
              "id": "C",
              "text": "Option D: Open surgical lung biopsy is inappropriate because definitive tissue diagnosis is required, but cross-sectional imaging should first define the lesion and determine the safest and highest-yield biopsy approach."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "C",
              "text": "Option D: Open surgical lung biopsy is inappropriate because definitive tissue diagnosis is required, but cross-sectional imaging should first define the lesion and determine the safest and highest-yield biopsy approach."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Open surgical lung biopsy is inappropriate because definitive tissue diagnosis is required, but cross-sectional imaging should first define the lesion and determine the safest and highest-yield biopsy approach."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "C",
              "text": "Option C: CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Open surgical lung biopsy is inappropriate because definitive tissue diagnosis is required, but cross-sectional imaging should first define the lesion and determine the safest and highest-yield biopsy approach."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Ventilation-perfusion scanning is used primarily when pulmonary embolism is suspected and CT angiography cannot be performed. It does not evaluate a suspected lung malignancy."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "C",
              "text": "Option C: CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Ventilation-perfusion scanning is used primarily when pulmonary embolism is suspected and CT angiography cannot be performed. It does not evaluate a suspected lung malignancy."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low-dose noncontrast CT scan of the chest for lung cancer screening is inappropriate because low-dose noncontrast CT is a screening examination for asymptomatic high-risk patients. This patient already has hemoptysis, weight loss, and a radiographically apparent pulmonary mass, so he needs diagnostic contrast-enhanced CT for characterization and staging."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "C",
              "text": "Option C: CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low-dose noncontrast CT scan of the chest for lung cancer screening is inappropriate because low-dose noncontrast CT is a screening examination for asymptomatic high-risk patients. This patient already has hemoptysis, weight loss, and a radiographically apparent pulmonary mass, so he needs diagnostic contrast-enhanced CT for characterization and staging."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Flexible bronchoscopy with endobronchial biopsy is inappropriate because bronchoscopy may provide tissue when CT demonstrates a central or endobronchial lesion. The lesion\u0027s relationship to the airways has not yet been defined, and guidelines recommend contrast-enhanced CT before any biopsy procedure."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "C",
              "text": "Option C: CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Flexible bronchoscopy with endobronchial biopsy is inappropriate because bronchoscopy may provide tissue when CT demonstrates a central or endobronchial lesion. The lesion\u0027s relationship to the airways has not yet been defined, and guidelines recommend contrast-enhanced CT before any biopsy procedure."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT-guided transthoracic needle biopsy of the opacity is inappropriate because a peripheral lesion may ultimately undergo image-guided biopsy, but diagnostic CT must first characterize the lesion, identify safer or higher-stage biopsy targets, and determine whether a percutaneous approach is appropriate."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "C",
              "text": "Option C: CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT-guided transthoracic needle biopsy of the opacity is inappropriate because a peripheral lesion may ultimately undergo image-guided biopsy, but diagnostic CT must first characterize the lesion, identify safer or higher-stage biopsy targets, and determine whether a percutaneous approach is appropriate."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Empiric antibiotics followed by repeat chest radiography in 6 weeks is inappropriate because short-interval radiographic follow-up after antibiotics can be reasonable when infection is the leading possibility. A 3.2-cm irregular opacity accompanied by hemoptysis, weight loss, and a 90-pack-year history requires prompt diagnostic CT rather than an empiric delay."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "C",
              "text": "Option C: CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Empiric antibiotics followed by repeat chest radiography in 6 weeks is inappropriate because short-interval radiographic follow-up after antibiotics can be reasonable when infection is the leading possibility. A 3.2-cm irregular opacity accompanied by hemoptysis, weight loss, and a 90-pack-year history requires prompt diagnostic CT rather than an empiric delay."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Pulmonary function testing helps quantify obstructive disease and assess fitness for lung resection. It neither characterizes nor diagnoses the suspicious opacity and therefore belongs later in the evaluation."
            },
            {
              "id": "B",
              "text": "Option B: Transthoracic echocardiography is inappropriate because echocardiography is appropriate when a cardiac cause of dyspnea or hemoptysis is suspected but does not evaluate a pulmonary mass."
            },
            {
              "id": "C",
              "text": "Option C: CT pulmonary angiography is indicated when pulmonary embolism is suspected. This patient\u0027s subacute symptoms, weight loss, and pulmonary mass are more consistent with malignancy."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Pulmonary function testing helps quantify obstructive disease and assess fitness for lung resection. It neither characterizes nor diagnoses the suspicious opacity and therefore belongs later in the evaluation."
        }
      }
    },
    {
      "externalId": "step3-pulmonary-pancoast-tumor-horner-syndrome-1431",
      "expectedHashes": {
        "ranaze_step3_uat": "c136e2b6953cf3e3b17b2948d386a4e45341576b5009da5ed9d1d3ad588d1b74",
        "ranaze_step3_prd": "c136e2b6953cf3e3b17b2948d386a4e45341576b5009da5ed9d1d3ad588d1b74"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "MRI of the brain is inappropriate because brain MRI is appropriate when a central neurologic lesion is suspected, but the combination of apical-distribution arm pain, Horner syndrome, smoking history, and weight loss localizes the lesion to the thoracic apex."
            },
            {
              "id": "B",
              "text": "Option C: Carotid duplex ultrasonography is inappropriate because carotid imaging may be indicated for acute painful Horner syndrome due to suspected carotid dissection, but this patient\u0027s progressive symptoms and lower brachial plexus findings favor an apical lung mass."
            },
            {
              "id": "C",
              "text": "Option D: Nerve conduction studies of the right upper extremity is inappropriate because electrodiagnostic testing may characterize a peripheral neuropathy but would not identify the suspected structural lesion compressing the sympathetic chain and brachial plexus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "MRI of the brain is inappropriate because brain MRI is appropriate when a central neurologic lesion is suspected, but the combination of apical-distribution arm pain, Horner syndrome, smoking history, and weight loss localizes the lesion to the thoracic apex."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Carotid duplex ultrasonography is inappropriate because carotid imaging may be indicated for acute painful Horner syndrome due to suspected carotid dissection, but this patient\u0027s progressive symptoms and lower brachial plexus findings favor an apical lung mass."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain is inappropriate because brain MRI is appropriate when a central neurologic lesion is suspected, but the combination of apical-distribution arm pain, Horner syndrome, smoking history, and weight loss localizes the lesion to the thoracic apex."
            },
            {
              "id": "C",
              "text": "Option D: Nerve conduction studies of the right upper extremity is inappropriate because electrodiagnostic testing may characterize a peripheral neuropathy but would not identify the suspected structural lesion compressing the sympathetic chain and brachial plexus."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Carotid duplex ultrasonography is inappropriate because carotid imaging may be indicated for acute painful Horner syndrome due to suspected carotid dissection, but this patient\u0027s progressive symptoms and lower brachial plexus findings favor an apical lung mass."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Nerve conduction studies of the right upper extremity is inappropriate because electrodiagnostic testing may characterize a peripheral neuropathy but would not identify the suspected structural lesion compressing the sympathetic chain and brachial plexus."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain is inappropriate because brain MRI is appropriate when a central neurologic lesion is suspected, but the combination of apical-distribution arm pain, Horner syndrome, smoking history, and weight loss localizes the lesion to the thoracic apex."
            },
            {
              "id": "C",
              "text": "Option C: Carotid duplex ultrasonography is inappropriate because carotid imaging may be indicated for acute painful Horner syndrome due to suspected carotid dissection, but this patient\u0027s progressive symptoms and lower brachial plexus findings favor an apical lung mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Nerve conduction studies of the right upper extremity is inappropriate because electrodiagnostic testing may characterize a peripheral neuropathy but would not identify the suspected structural lesion compressing the sympathetic chain and brachial plexus."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Fluorescein examination of the cornea is inappropriate because fluorescein staining evaluates corneal epithelial injury and is unrelated to ptosis, miosis, and radiating shoulder pain."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain is inappropriate because brain MRI is appropriate when a central neurologic lesion is suspected, but the combination of apical-distribution arm pain, Horner syndrome, smoking history, and weight loss localizes the lesion to the thoracic apex."
            },
            {
              "id": "C",
              "text": "Option C: Carotid duplex ultrasonography is inappropriate because carotid imaging may be indicated for acute painful Horner syndrome due to suspected carotid dissection, but this patient\u0027s progressive symptoms and lower brachial plexus findings favor an apical lung mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Fluorescein examination of the cornea is inappropriate because fluorescein staining evaluates corneal epithelial injury and is unrelated to ptosis, miosis, and radiating shoulder pain."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Flexible bronchoscopy with endobronchial biopsy is inappropriate because bronchoscopy is performed after imaging when tissue sampling is needed and has a relatively low yield for a peripheral superior sulcus lesion unless there is endobronchial involvement. It is not the initial diagnostic study."
            },
            {
              "id": "B",
              "text": "Option B: MRI of the brain is inappropriate because brain MRI is appropriate when a central neurologic lesion is suspected, but the combination of apical-distribution arm pain, Horner syndrome, smoking history, and weight loss localizes the lesion to the thoracic apex."
            },
            {
              "id": "C",
              "text": "Option C: Carotid duplex ultrasonography is inappropriate because carotid imaging may be indicated for acute painful Horner syndrome due to suspected carotid dissection, but this patient\u0027s progressive symptoms and lower brachial plexus findings favor an apical lung mass."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Flexible bronchoscopy with endobronchial biopsy is inappropriate because bronchoscopy is performed after imaging when tissue sampling is needed and has a relatively low yield for a peripheral superior sulcus lesion unless there is endobronchial involvement. It is not the initial diagnostic study."
        }
      }
    },
    {
      "externalId": "step3-pulmonology-copd-secondary-polycythemia-2684",
      "expectedHashes": {
        "ranaze_step3_uat": "2c041b118a90ead4939efee6175140703b80cf33c45ec5de0b8dae257e41e610",
        "ranaze_step3_prd": "2c041b118a90ead4939efee6175140703b80cf33c45ec5de0b8dae257e41e610"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Bone marrow biopsy showing panmyelosis is inappropriate because panmyelosis supports polycythemia vera, which may also cause leukocytosis, thrombocytosis, splenomegaly, and suppressed erythropoietin."
            },
            {
              "id": "B",
              "text": "Option C: CT scan of the chest demonstrating a pulmonary mass is inappropriate because a pulmonary mass is not needed to explain erythrocytosis in a patient with documented severe hypoxemia from COPD."
            },
            {
              "id": "C",
              "text": "Option D: Low serum erythropoietin concentration is inappropriate because hypoxia-induced secondary erythrocytosis is associated with elevated or inappropriately normal, not suppressed, erythropoietin."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Bone marrow biopsy showing panmyelosis is inappropriate because panmyelosis supports polycythemia vera, which may also cause leukocytosis, thrombocytosis, splenomegaly, and suppressed erythropoietin."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "CT scan of the chest demonstrating a pulmonary mass is inappropriate because a pulmonary mass is not needed to explain erythrocytosis in a patient with documented severe hypoxemia from COPD."
            },
            {
              "id": "B",
              "text": "Option B: Bone marrow biopsy showing panmyelosis is inappropriate because panmyelosis supports polycythemia vera, which may also cause leukocytosis, thrombocytosis, splenomegaly, and suppressed erythropoietin."
            },
            {
              "id": "C",
              "text": "Option D: Low serum erythropoietin concentration is inappropriate because hypoxia-induced secondary erythrocytosis is associated with elevated or inappropriately normal, not suppressed, erythropoietin."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "CT scan of the chest demonstrating a pulmonary mass is inappropriate because a pulmonary mass is not needed to explain erythrocytosis in a patient with documented severe hypoxemia from COPD."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Low serum erythropoietin concentration is inappropriate because hypoxia-induced secondary erythrocytosis is associated with elevated or inappropriately normal, not suppressed, erythropoietin."
            },
            {
              "id": "B",
              "text": "Option B: Bone marrow biopsy showing panmyelosis is inappropriate because panmyelosis supports polycythemia vera, which may also cause leukocytosis, thrombocytosis, splenomegaly, and suppressed erythropoietin."
            },
            {
              "id": "C",
              "text": "Option C: CT scan of the chest demonstrating a pulmonary mass is inappropriate because a pulmonary mass is not needed to explain erythrocytosis in a patient with documented severe hypoxemia from COPD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Low serum erythropoietin concentration is inappropriate because hypoxia-induced secondary erythrocytosis is associated with elevated or inappropriately normal, not suppressed, erythropoietin."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Renal ultrasonography demonstrating bilateral renal cysts is inappropriate because some renal lesions can cause inappropriate erythropoietin production, but chronic hypoxemia is the direct explanation in this patient."
            },
            {
              "id": "B",
              "text": "Option B: Bone marrow biopsy showing panmyelosis is inappropriate because panmyelosis supports polycythemia vera, which may also cause leukocytosis, thrombocytosis, splenomegaly, and suppressed erythropoietin."
            },
            {
              "id": "C",
              "text": "Option C: CT scan of the chest demonstrating a pulmonary mass is inappropriate because a pulmonary mass is not needed to explain erythrocytosis in a patient with documented severe hypoxemia from COPD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Renal ultrasonography demonstrating bilateral renal cysts is inappropriate because some renal lesions can cause inappropriate erythropoietin production, but chronic hypoxemia is the direct explanation in this patient."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Polysomnography demonstrating obstructive sleep apnea is inappropriate because obstructive sleep apnea can cause hypoxia-driven erythrocytosis, but no sleep-related symptoms are provided. Severe COPD with an awake room-air oxygen saturation of 84% already supplies the most likely cause."
            },
            {
              "id": "B",
              "text": "Option B: Bone marrow biopsy showing panmyelosis is inappropriate because panmyelosis supports polycythemia vera, which may also cause leukocytosis, thrombocytosis, splenomegaly, and suppressed erythropoietin."
            },
            {
              "id": "C",
              "text": "Option C: CT scan of the chest demonstrating a pulmonary mass is inappropriate because a pulmonary mass is not needed to explain erythrocytosis in a patient with documented severe hypoxemia from COPD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Polysomnography demonstrating obstructive sleep apnea is inappropriate because obstructive sleep apnea can cause hypoxia-driven erythrocytosis, but no sleep-related symptoms are provided. Severe COPD with an awake room-air oxygen saturation of 84% already supplies the most likely cause."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hemoglobin P50 testing demonstrating a high-oxygen-affinity hemoglobin variant is inappropriate because p50 testing is reasonable in otherwise unexplained erythrocytosis and can identify a high-affinity hemoglobin variant. A newly recognized congenital hemoglobinopathy at age 60 is unlikely when severe COPD and an oxygen saturation of 84% directly explain the erythrocytosis."
            },
            {
              "id": "B",
              "text": "Option B: Bone marrow biopsy showing panmyelosis is inappropriate because panmyelosis supports polycythemia vera, which may also cause leukocytosis, thrombocytosis, splenomegaly, and suppressed erythropoietin."
            },
            {
              "id": "C",
              "text": "Option C: CT scan of the chest demonstrating a pulmonary mass is inappropriate because a pulmonary mass is not needed to explain erythrocytosis in a patient with documented severe hypoxemia from COPD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hemoglobin P50 testing demonstrating a high-oxygen-affinity hemoglobin variant is inappropriate because p50 testing is reasonable in otherwise unexplained erythrocytosis and can identify a high-affinity hemoglobin variant. A newly recognized congenital hemoglobinopathy at age 60 is unlikely when severe COPD and an oxygen saturation of 84% directly explain the erythrocytosis."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Repeat complete blood count after hydration demonstrating normalization of the hematocrit is inappropriate because normalization after hydration would indicate relative erythrocytosis from plasma-volume contraction. The stem supplies no evidence of dehydration and instead shows marked resting hypoxemia capable of producing true secondary erythrocytosis."
            },
            {
              "id": "B",
              "text": "Option B: Bone marrow biopsy showing panmyelosis is inappropriate because panmyelosis supports polycythemia vera, which may also cause leukocytosis, thrombocytosis, splenomegaly, and suppressed erythropoietin."
            },
            {
              "id": "C",
              "text": "Option C: CT scan of the chest demonstrating a pulmonary mass is inappropriate because a pulmonary mass is not needed to explain erythrocytosis in a patient with documented severe hypoxemia from COPD."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Repeat complete blood count after hydration demonstrating normalization of the hematocrit is inappropriate because normalization after hydration would indicate relative erythrocytosis from plasma-volume contraction. The stem supplies no evidence of dehydration and instead shows marked resting hypoxemia capable of producing true secondary erythrocytosis."
        }
      }
    },
    {
      "externalId": "step3-quality-improvement-standardization-process-1372",
      "expectedHashes": {
        "ranaze_step3_uat": "58ae3752a9f62c01429c08bb6d5a5d238a666347b36589a54f47d0708f7284eb",
        "ranaze_step3_prd": "58ae3752a9f62c01429c08bb6d5a5d238a666347b36589a54f47d0708f7284eb"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "B",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            },
            {
              "id": "C",
              "text": "Option D: Conduct mandatory staff education on the current referral process is inappropriate because training staff on an inconsistent process reinforces existing variation rather than eliminating it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option D: Conduct mandatory staff education on the current referral process is inappropriate because training staff on an inconsistent process reinforces existing variation rather than eliminating it."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Conduct mandatory staff education on the current referral process is inappropriate because training staff on an inconsistent process reinforces existing variation rather than eliminating it."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Conduct mandatory staff education on the current referral process is inappropriate because training staff on an inconsistent process reinforces existing variation rather than eliminating it."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Require referring physicians to contact the anticoagulation clinic if they have not received confirmation within 72 hours is inappropriate because having physicians follow up adds another step and shifts responsibility to the end user instead of fixing the defective system."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Require referring physicians to contact the anticoagulation clinic if they have not received confirmation within 72 hours is inappropriate because having physicians follow up adds another step and shifts responsibility to the end user instead of fixing the defective system."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hire an additional referral coordinator to help process the existing shared inbox is inappropriate because additional staffing may increase processing capacity, but the stem identifies defects caused by variable forms, requirements, and documentation. Adding personnel to an unreliable process does not remove those sources of variation."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hire an additional referral coordinator to help process the existing shared inbox is inappropriate because additional staffing may increase processing capacity, but the stem identifies defects caused by variable forms, requirements, and documentation. Adding personnel to an unreliable process does not remove those sources of variation."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Require a second nurse to verify every referral before it is placed in the shared inbox is inappropriate because a redundant inspection step may catch some errors but increases workload and handoffs without preventing clinics from submitting inconsistent or incomplete information. Reliability is better improved by designing required information into one standard process."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Require a second nurse to verify every referral before it is placed in the shared inbox is inappropriate because a redundant inspection step may catch some errors but increases workload and handoffs without preventing clinics from submitting inconsistent or incomplete information. Reliability is better improved by designing required information into one standard process."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Immediately return all incomplete referrals to the referring clinic without processing them is inappropriate because returning incomplete referrals detects a defect after it occurs and creates additional delay. A single form with required fields prevents many incomplete submissions at their source."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Immediately return all incomplete referrals to the referring clinic without processing them is inappropriate because returning incomplete referrals detects a defect after it occurs and creates additional delay. A single form with required fields prevents many incomplete submissions at their source."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Send physicians monthly reports comparing their referral turnaround times is inappropriate because performance feedback can help sustain improvement, but reporting outcomes does not itself correct the multiple workflows producing omissions and lost referrals. The process should first be standardized."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Send physicians monthly reports comparing their referral turnaround times is inappropriate because performance feedback can help sustain improvement, but reporting outcomes does not itself correct the multiple workflows producing omissions and lost referrals. The process should first be standardized."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Issue formal warnings to staff members involved when a referral is misplaced is inappropriate because punishing individual staff members applies a person-focused response to a system-level problem. The widespread use of different templates, requirements, and documentation methods indicates that the workflow\u2014not isolated misconduct\u2014is the principal source of failure."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Issue formal warnings to staff members involved when a referral is misplaced is inappropriate because punishing individual staff members applies a person-focused response to a system-level problem. The widespread use of different templates, requirements, and documentation methods indicates that the workflow\u2014not isolated misconduct\u2014is the principal source of failure."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Add an automated alert when a referral has remained in the inbox for 48 hours is inappropriate because an alert at 48 hours identifies delay only after the stated turnaround target has already been reached. It does not correct the variable submission and documentation processes that create defects."
            },
            {
              "id": "B",
              "text": "Option B: Require the referral coordinator to review the shared inbox every morning is inappropriate because checking the inbox more frequently may modestly shorten delays but does not address the underlying process variation causing incomplete and lost referrals."
            },
            {
              "id": "C",
              "text": "Option C: Provide financial incentives to clinics that achieve a referral turnaround time of less than 48 hours is inappropriate because financial incentives do not correct a poorly designed workflow and may encourage workarounds rather than sustainable improvement."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Add an automated alert when a referral has remained in the inbox for 48 hours is inappropriate because an alert at 48 hours identifies delay only after the stated turnaround target has already been reached. It does not correct the variable submission and documentation processes that create defects."
        }
      }
    },
    {
      "externalId": "step3-rheumatology-cppd-acute-treatment-734",
      "expectedHashes": {
        "ranaze_step3_uat": "38dc67f5ea5dfd2b66382b1af4d9c23f404c9d72a66d2d90840d2c8f81f5cdb5",
        "ranaze_step3_prd": "38dc67f5ea5dfd2b66382b1af4d9c23f404c9d72a66d2d90840d2c8f81f5cdb5"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
            },
            {
              "id": "B",
              "text": "Option C: Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
            },
            {
              "id": "C",
              "text": "Option D: Begin allopurinol therapy is inappropriate because allopurinol lowers uric acid and is used for gout prevention; it does not treat calcium pyrophosphate deposition disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
            },
            {
              "id": "B",
              "text": "Option B: Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
            },
            {
              "id": "C",
              "text": "Option D: Begin allopurinol therapy is inappropriate because allopurinol lowers uric acid and is used for gout prevention; it does not treat calcium pyrophosphate deposition disease."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin allopurinol therapy is inappropriate because allopurinol lowers uric acid and is used for gout prevention; it does not treat calcium pyrophosphate deposition disease."
            },
            {
              "id": "B",
              "text": "Option B: Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
            },
            {
              "id": "C",
              "text": "Option C: Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin allopurinol therapy is inappropriate because allopurinol lowers uric acid and is used for gout prevention; it does not treat calcium pyrophosphate deposition disease."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Increase amlodipine dosage is inappropriate because amlodipine treats hypertension and has no role in crystal-induced arthritis."
            },
            {
              "id": "B",
              "text": "Option B: Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
            },
            {
              "id": "C",
              "text": "Option C: Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Increase amlodipine dosage is inappropriate because amlodipine treats hypertension and has no role in crystal-induced arthritis."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Start hydroxychloroquine therapy is inappropriate because hydroxychloroquine may be considered for selected chronic inflammatory CPPD, but it does not provide appropriate first-line control of an abrupt 3-day acute flare."
            },
            {
              "id": "B",
              "text": "Option B: Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
            },
            {
              "id": "C",
              "text": "Option C: Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Start hydroxychloroquine therapy is inappropriate because hydroxychloroquine may be considered for selected chronic inflammatory CPPD, but it does not provide appropriate first-line control of an abrupt 3-day acute flare."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Perform arthroscopic irrigation and debridement of the right knee is inappropriate because arthroscopic irrigation and debridement is used to drain septic arthritis. It is unnecessarily invasive for crystal-proven CPP arthritis when bacterial studies are negative."
            },
            {
              "id": "B",
              "text": "Option B: Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
            },
            {
              "id": "C",
              "text": "Option C: Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Perform arthroscopic irrigation and debridement of the right knee is inappropriate because arthroscopic irrigation and debridement is used to drain septic arthritis. It is unnecessarily invasive for crystal-proven CPP arthritis when bacterial studies are negative."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Initiate urgent therapeutic phlebotomy is inappropriate because phlebotomy treats the systemic iron overload of hemochromatosis but does not remove deposited CPP crystals or abort an acute CPP arthritis flare. The immediate joint inflammation requires anti-inflammatory therapy."
            },
            {
              "id": "B",
              "text": "Option B: Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
            },
            {
              "id": "C",
              "text": "Option C: Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Initiate urgent therapeutic phlebotomy is inappropriate because phlebotomy treats the systemic iron overload of hemochromatosis but does not remove deposited CPP crystals or abort an acute CPP arthritis flare. The immediate joint inflammation requires anti-inflammatory therapy."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Obtain a serum uric acid level before beginning treatment is inappropriate because serum uric acid does not establish or exclude an acute crystal arthritis diagnosis and would not change this case, because synovial microscopy has already identified CPP crystals. Delaying treatment for it is unnecessary."
            },
            {
              "id": "B",
              "text": "Option B: Start high-dose methotrexate therapy is inappropriate because methotrexate is not first-line treatment for an acute crystal-induced arthritis flare; it is reserved only for selected refractory chronic inflammatory CPPD presentations."
            },
            {
              "id": "C",
              "text": "Option C: Increase acetaminophen use and recommend strict bed rest is inappropriate because acetaminophen may reduce pain but does not adequately treat the inflammatory process, and strict bed rest can worsen mobility and deconditioning."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Obtain a serum uric acid level before beginning treatment is inappropriate because serum uric acid does not establish or exclude an acute crystal arthritis diagnosis and would not change this case, because synovial microscopy has already identified CPP crystals. Delaying treatment for it is unnecessary."
        }
      }
    },
    {
      "externalId": "step3-seed-001",
      "expectedHashes": {
        "ranaze_step3_uat": "c4b6b01e2f3fbe114baa76b11ac9fd83140433e370ae0e26d5873114d5f231ed",
        "ranaze_step3_prd": "c4b6b01e2f3fbe114baa76b11ac9fd83140433e370ae0e26d5873114d5f231ed"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "B",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            },
            {
              "id": "C",
              "text": "Option D: Give intravenous furosemide is inappropriate because diuresis would worsen shock unless there is clear fluid overload after stabilization."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option D: Give intravenous furosemide is inappropriate because diuresis would worsen shock unless there is clear fluid overload after stabilization."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give intravenous furosemide is inappropriate because diuresis would worsen shock unless there is clear fluid overload after stabilization."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give intravenous furosemide is inappropriate because diuresis would worsen shock unless there is clear fluid overload after stabilization."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Switch antibiotics to oral doxycycline only is inappropriate because oral monotherapy is inadequate for this unstable hospitalized patient."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Switch antibiotics to oral doxycycline only is inappropriate because oral monotherapy is inadequate for this unstable hospitalized patient."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use intravenous dopamine as the first-line vasopressor is inappropriate because norepinephrine is preferred to dopamine as first-line therapy in septic shock. Dopamine produces more tachyarrhythmias, an especially important concern with a pulse of 124/min."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use intravenous dopamine as the first-line vasopressor is inappropriate because norepinephrine is preferred to dopamine as first-line therapy in septic shock. Dopamine produces more tachyarrhythmias, an especially important concern with a pulse of 124/min."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Use intravenous epinephrine as the first-line vasopressor is inappropriate because current guidelines recommend norepinephrine over epinephrine for routine first-line treatment. Epinephrine may be considered with concomitant cardiac dysfunction or after inadequate response to norepinephrine and vasopressin; neither circumstance is presented, and this patient is markedly tachycardic."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Use intravenous epinephrine as the first-line vasopressor is inappropriate because current guidelines recommend norepinephrine over epinephrine for routine first-line treatment. Epinephrine may be considered with concomitant cardiac dysfunction or after inadequate response to norepinephrine and vasopressin; neither circumstance is presented, and this patient is markedly tachycardic."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin vasopressin monotherapy instead of norepinephrine is inappropriate because vasopressin is generally added when norepinephrine requirements escalate, not used as initial monotherapy in an otherwise typical vasodilatory septic shock presentation."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin vasopressin monotherapy instead of norepinephrine is inappropriate because vasopressin is generally added when norepinephrine requirements escalate, not used as initial monotherapy in an otherwise typical vasodilatory septic shock presentation."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Begin dobutamine monotherapy is inappropriate because dobutamine is an inotrope for documented cardiac dysfunction with persistent hypoperfusion despite adequate volume and arterial pressure. It should not replace a vasopressor when MAP is 58 mm Hg."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Begin dobutamine monotherapy is inappropriate because dobutamine is an inotrope for documented cardiac dysfunction with persistent hypoperfusion despite adequate volume and arterial pressure. It should not replace a vasopressor when MAP is 58 mm Hg."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Administer intravenous hydrocortisone instead of starting a vasopressor is inappropriate because corticosteroids may be considered in septic shock with an ongoing vasopressor requirement. Hydrocortisone does not replace the immediate first-line vasopressor needed for persistent fluid-refractory hypotension."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Administer intravenous hydrocortisone instead of starting a vasopressor is inappropriate because corticosteroids may be considered in septic shock with an ongoing vasopressor requirement. Hydrocortisone does not replace the immediate first-line vasopressor needed for persistent fluid-refractory hypotension."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Give another fixed 30 mL/kg crystalloid bolus and withhold vasopressors until it is completed is inappropriate because after the initial 30 mL/kg, further fluid should be individualized using perfusion and fluid-responsiveness assessment. A mandatory second large bolus must not delay vasopressor treatment of a MAP of 58 mm Hg."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Give another fixed 30 mL/kg crystalloid bolus and withhold vasopressors until it is completed is inappropriate because after the initial 30 mL/kg, further fluid should be individualized using perfusion and fluid-responsiveness assessment. A mandatory second large bolus must not delay vasopressor treatment of a MAP of 58 mm Hg."
        },
        "L": {
          "prompt": "Which feature of option L should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Wait for central venous catheter placement before starting norepinephrine is inappropriate because norepinephrine can be started through an appropriate proximal peripheral vein while central access is arranged. Waiting for a central catheter unnecessarily prolongs severe hypotension."
            },
            {
              "id": "B",
              "text": "Option B: Begin oral prednisone and discharge home is inappropriate because outpatient treatment is inappropriate in shock and hypoxemia."
            },
            {
              "id": "C",
              "text": "Option C: Delay vasopressors until blood cultures finalize is inappropriate because vasopressors should not be delayed while awaiting culture results in persistent septic shock."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Wait for central venous catheter placement before starting norepinephrine is inappropriate because norepinephrine can be started through an appropriate proximal peripheral vein while central access is arranged. Waiting for a central catheter unnecessarily prolongs severe hypotension."
        }
      }
    },
    {
      "externalId": "step3-surgery-postoperative-pulmonary-embolism-1714",
      "expectedHashes": {
        "ranaze_step3_uat": "21c101af917a2c517ed6a4e0d3975ed85005cabcfda754cf0138df3e041ae4a4",
        "ranaze_step3_prd": "21c101af917a2c517ed6a4e0d3975ed85005cabcfda754cf0138df3e041ae4a4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "B",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            },
            {
              "id": "C",
              "text": "Option D: Acute respiratory distress syndrome is inappropriate because aRDS causes diffuse inflammatory lung injury with refractory hypoxemia, typically following a major systemic insult, but does not usually present as sudden obstructive shock with clear lungs and distended neck veins."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option D: Acute respiratory distress syndrome is inappropriate because aRDS causes diffuse inflammatory lung injury with refractory hypoxemia, typically following a major systemic insult, but does not usually present as sudden obstructive shock with clear lungs and distended neck veins."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute respiratory distress syndrome is inappropriate because aRDS causes diffuse inflammatory lung injury with refractory hypoxemia, typically following a major systemic insult, but does not usually present as sudden obstructive shock with clear lungs and distended neck veins."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute respiratory distress syndrome is inappropriate because aRDS causes diffuse inflammatory lung injury with refractory hypoxemia, typically following a major systemic insult, but does not usually present as sudden obstructive shock with clear lungs and distended neck veins."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute decompensated left-sided heart failure is inappropriate because left-sided heart failure commonly causes pulmonary crackles, orthopnea, and pulmonary edema rather than clear breath sounds and acute right-sided pressure findings."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute decompensated left-sided heart failure is inappropriate because left-sided heart failure commonly causes pulmonary crackles, orthopnea, and pulmonary edema rather than clear breath sounds and acute right-sided pressure findings."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Tension pneumothorax from positive-pressure ventilation is inappropriate because positive-pressure ventilation is a risk factor for tension pneumothorax, which can cause sudden hypoxemia, hypotension, and jugular venous distention. However, tension pneumothorax should cause markedly reduced or absent unilateral breath sounds; breath sounds are clear bilaterally here."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Tension pneumothorax from positive-pressure ventilation is inappropriate because positive-pressure ventilation is a risk factor for tension pneumothorax, which can cause sudden hypoxemia, hypotension, and jugular venous distention. However, tension pneumothorax should cause markedly reduced or absent unilateral breath sounds; breath sounds are clear bilaterally here."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute cardiac tamponade is inappropriate because tamponade can cause hypotension and distended neck veins with relatively clear lungs, but there is no pericardial procedure, trauma, or other precipitating clue. The profound acute hypoxemia in a patient with cancer, major abdominal surgery, and immobility much more strongly supports pulmonary embolism."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute cardiac tamponade is inappropriate because tamponade can cause hypotension and distended neck veins with relatively clear lungs, but there is no pericardial procedure, trauma, or other precipitating clue. The profound acute hypoxemia in a patient with cancer, major abdominal surgery, and immobility much more strongly supports pulmonary embolism."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute right ventricular myocardial infarction is inappropriate because right ventricular infarction can cause hypotension and jugular venous distention without pulmonary edema. It does not as readily explain sudden severe refractory hypoxemia, and the stem supplies multiple powerful venous thromboembolism risks."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute right ventricular myocardial infarction is inappropriate because right ventricular infarction can cause hypotension and jugular venous distention without pulmonary edema. It does not as readily explain sudden severe refractory hypoxemia, and the stem supplies multiple powerful venous thromboembolism risks."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Postoperative intra-abdominal hemorrhage is inappropriate because postoperative hemorrhage can cause abrupt tachycardia and hypotension, but hypovolemia would not produce distended neck veins. The clean wound, lack of abdominal rigidity, and severe hypoxemia also favor obstructive shock from pulmonary embolism."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Postoperative intra-abdominal hemorrhage is inappropriate because postoperative hemorrhage can cause abrupt tachycardia and hypotension, but hypovolemia would not produce distended neck veins. The clean wound, lack of abdominal rigidity, and severe hypoxemia also favor obstructive shock from pulmonary embolism."
        },
        "J": {
          "prompt": "Which feature of option J should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Aspiration pneumonitis may cause abrupt hypoxemia in an intubated patient, usually with cough, wheezing, crackles, or radiographic infiltrates. It does not explain distended neck veins and obstructive shock as well as massive pulmonary embolism."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Aspiration pneumonitis may cause abrupt hypoxemia in an intubated patient, usually with cough, wheezing, crackles, or radiographic infiltrates. It does not explain distended neck veins and obstructive shock as well as massive pulmonary embolism."
        },
        "K": {
          "prompt": "Which feature of option K should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute exacerbation of chronic obstructive pulmonary disease is inappropriate because smoking raises the possibility of COPD, but an exacerbation generally causes wheezing, prolonged expiration, and hypercapnic respiratory distress rather than sudden obstructive shock with distended neck veins and clear breath sounds."
            },
            {
              "id": "B",
              "text": "Option B: Postoperative atelectasis is inappropriate because atelectasis commonly causes mild postoperative hypoxemia but usually develops gradually and does not cause profound hypotension or jugular venous distention."
            },
            {
              "id": "C",
              "text": "Option C: Hospital-acquired pneumonia generally causes fever, purulent secretions, focal pulmonary findings, and a more progressive decline rather than abrupt cardiovascular collapse."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute exacerbation of chronic obstructive pulmonary disease is inappropriate because smoking raises the possibility of COPD, but an exacerbation generally causes wheezing, prolonged expiration, and hypercapnic respiratory distress rather than sudden obstructive shock with distended neck veins and clear breath sounds."
        }
      }
    },
    {
      "externalId": "step3-surgery-postoperative-seroma-816",
      "expectedHashes": {
        "ranaze_step3_uat": "770d388efd21318ba965d1ee91b21f0eb50287383b74c1b45b20182457d731b4",
        "ranaze_step3_prd": "770d388efd21318ba965d1ee91b21f0eb50287383b74c1b45b20182457d731b4"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Surgical-site abscess is inappropriate because an abscess usually causes increasing pain, erythema, warmth, tenderness, purulent drainage, and sometimes fever."
            },
            {
              "id": "B",
              "text": "Option C: Postoperative hematoma is inappropriate because a hematoma generally appears soon after surgery and may be firm, painful, ecchymotic, or associated with bloody drainage."
            },
            {
              "id": "C",
              "text": "Option D: Cellulitis causes diffuse erythema, warmth, tenderness, and swelling rather than a discrete fluctuant fluid collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Surgical-site abscess is inappropriate because an abscess usually causes increasing pain, erythema, warmth, tenderness, purulent drainage, and sometimes fever."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Postoperative hematoma is inappropriate because a hematoma generally appears soon after surgery and may be firm, painful, ecchymotic, or associated with bloody drainage."
            },
            {
              "id": "B",
              "text": "Option B: Surgical-site abscess is inappropriate because an abscess usually causes increasing pain, erythema, warmth, tenderness, purulent drainage, and sometimes fever."
            },
            {
              "id": "C",
              "text": "Option D: Cellulitis causes diffuse erythema, warmth, tenderness, and swelling rather than a discrete fluctuant fluid collection."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Postoperative hematoma is inappropriate because a hematoma generally appears soon after surgery and may be firm, painful, ecchymotic, or associated with bloody drainage."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Cellulitis causes diffuse erythema, warmth, tenderness, and swelling rather than a discrete fluctuant fluid collection."
            },
            {
              "id": "B",
              "text": "Option B: Surgical-site abscess is inappropriate because an abscess usually causes increasing pain, erythema, warmth, tenderness, purulent drainage, and sometimes fever."
            },
            {
              "id": "C",
              "text": "Option C: Postoperative hematoma is inappropriate because a hematoma generally appears soon after surgery and may be firm, painful, ecchymotic, or associated with bloody drainage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Cellulitis causes diffuse erythema, warmth, tenderness, and swelling rather than a discrete fluctuant fluid collection."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Recurrent soft-tissue tumor is inappropriate because tumor recurrence would not usually develop within 8 days or produce a freely shifting fluid wave."
            },
            {
              "id": "B",
              "text": "Option B: Surgical-site abscess is inappropriate because an abscess usually causes increasing pain, erythema, warmth, tenderness, purulent drainage, and sometimes fever."
            },
            {
              "id": "C",
              "text": "Option C: Postoperative hematoma is inappropriate because a hematoma generally appears soon after surgery and may be firm, painful, ecchymotic, or associated with bloody drainage."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Recurrent soft-tissue tumor is inappropriate because tumor recurrence would not usually develop within 8 days or produce a freely shifting fluid wave."
        }
      }
    },
    {
      "externalId": "step3-urogynecology-stress-incontinence-cystocele-3156",
      "expectedHashes": {
        "ranaze_step3_uat": "2753f1afaa760beb8c727e61ff5f0143754f612504a21327c0091dfe610dd219",
        "ranaze_step3_prd": "2753f1afaa760beb8c727e61ff5f0143754f612504a21327c0091dfe610dd219"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
            },
            {
              "id": "B",
              "text": "Option C: Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
            },
            {
              "id": "C",
              "text": "Option D: An enlarged irregular uterus suggests leiomyomas, which may cause pelvic pressure or urinary frequency but do not establish stress incontinence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
            },
            {
              "id": "B",
              "text": "Option B: Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
            },
            {
              "id": "C",
              "text": "Option D: An enlarged irregular uterus suggests leiomyomas, which may cause pelvic pressure or urinary frequency but do not establish stress incontinence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "An enlarged irregular uterus suggests leiomyomas, which may cause pelvic pressure or urinary frequency but do not establish stress incontinence."
            },
            {
              "id": "B",
              "text": "Option B: Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
            },
            {
              "id": "C",
              "text": "Option C: Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "An enlarged irregular uterus suggests leiomyomas, which may cause pelvic pressure or urinary frequency but do not establish stress incontinence."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Severe vaginal mucosal atrophy is inappropriate because vaginal atrophy may cause irritation, dyspareunia, or urinary symptoms after menopause but is not diagnostic of stress incontinence."
            },
            {
              "id": "B",
              "text": "Option B: Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
            },
            {
              "id": "C",
              "text": "Option C: Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Severe vaginal mucosal atrophy is inappropriate because vaginal atrophy may cause irritation, dyspareunia, or urinary symptoms after menopause but is not diagnostic of stress incontinence."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Urethral rotation greater than 30 degrees during a Q-tip test is inappropriate because a positive Q-tip test indicates urethral hypermobility, which may accompany stress incontinence but neither proves that leakage occurs nor identifies its timing. Directly observed synchronous urethral leakage during coughing is more specific."
            },
            {
              "id": "B",
              "text": "Option B: Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
            },
            {
              "id": "C",
              "text": "Option C: Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Urethral rotation greater than 30 degrees during a Q-tip test is inappropriate because a positive Q-tip test indicates urethral hypermobility, which may accompany stress incontinence but neither proves that leakage occurs nor identifies its timing. Directly observed synchronous urethral leakage during coughing is more specific."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A palpably distended bladder after voiding is inappropriate because a bladder that remains distended after voiding suggests urinary retention and overflow incontinence. This patient instead has discrete leakage with increases in intra-abdominal pressure and no continuous dribbling."
            },
            {
              "id": "B",
              "text": "Option B: Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
            },
            {
              "id": "C",
              "text": "Option C: Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A palpably distended bladder after voiding is inappropriate because a bladder that remains distended after voiding suggests urinary retention and overflow incontinence. This patient instead has discrete leakage with increases in intra-abdominal pressure and no continuous dribbling."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Continuous pooling of clear fluid in the vagina is inappropriate because continuous vaginal pooling of urine suggests a genitourinary fistula and would fit continuous leakage. The patient explicitly denies continuous dribbling and reports exertional episodes."
            },
            {
              "id": "B",
              "text": "Option B: Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
            },
            {
              "id": "C",
              "text": "Option C: Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Continuous pooling of clear fluid in the vagina is inappropriate because continuous vaginal pooling of urine suggests a genitourinary fistula and would fit continuous leakage. The patient explicitly denies continuous dribbling and reports exertional episodes."
        },
        "I": {
          "prompt": "Which feature of option I should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A tender anterior vaginal-wall mass that expresses discharge through the urethra is inappropriate because a tender anterior vaginal-wall mass with urethral discharge suggests a urethral diverticulum. Diverticula more often cause dysuria, dyspareunia, recurrent infection, or postvoid dribbling, none of which explains this classic exertional pattern."
            },
            {
              "id": "B",
              "text": "Option B: Anterior vaginal wall prolapse with straining is inappropriate because a cystocele reflects pelvic-floor weakness and may coexist with stress incontinence, but it does not directly establish that stress causes the urine leakage."
            },
            {
              "id": "C",
              "text": "Option C: Absent anal wink reflex is inappropriate because an absent anal wink suggests sacral neurologic dysfunction and raises concern for neurogenic bladder rather than uncomplicated stress incontinence."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A tender anterior vaginal-wall mass that expresses discharge through the urethra is inappropriate because a tender anterior vaginal-wall mass with urethral discharge suggests a urethral diverticulum. Diverticula more often cause dysuria, dyspareunia, recurrent infection, or postvoid dribbling, none of which explains this classic exertional pattern."
        }
      }
    },
    {
      "externalId": "step3-urology-acute-bacterial-prostatitis-4821",
      "expectedHashes": {
        "ranaze_step3_uat": "fe00867babff6a4efda4cdcc8770275f6ac8d12eb58f98ff36c3d78a3724a22d",
        "ranaze_step3_prd": "fe00867babff6a4efda4cdcc8770275f6ac8d12eb58f98ff36c3d78a3724a22d"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute pyelonephritis is inappropriate because pyelonephritis typically causes fever with flank pain and costovertebral angle tenderness rather than marked prostatic tenderness."
            },
            {
              "id": "B",
              "text": "Option C: Acute epididymitis causes unilateral scrotal pain and tenderness localized to the epididymis rather than perineal pain and prostate tenderness."
            },
            {
              "id": "C",
              "text": "Option D: Acute uncomplicated cystitis is inappropriate because acute cystitis causes dysuria, urgency, and frequency but does not explain the high fever, chills, and markedly tender prostate; moreover, a urinary infection in a man is not classified as uncomplicated cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute pyelonephritis is inappropriate because pyelonephritis typically causes fever with flank pain and costovertebral angle tenderness rather than marked prostatic tenderness."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute epididymitis causes unilateral scrotal pain and tenderness localized to the epididymis rather than perineal pain and prostate tenderness."
            },
            {
              "id": "B",
              "text": "Option B: Acute pyelonephritis is inappropriate because pyelonephritis typically causes fever with flank pain and costovertebral angle tenderness rather than marked prostatic tenderness."
            },
            {
              "id": "C",
              "text": "Option D: Acute uncomplicated cystitis is inappropriate because acute cystitis causes dysuria, urgency, and frequency but does not explain the high fever, chills, and markedly tender prostate; moreover, a urinary infection in a man is not classified as uncomplicated cystitis."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute epididymitis causes unilateral scrotal pain and tenderness localized to the epididymis rather than perineal pain and prostate tenderness."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Acute uncomplicated cystitis is inappropriate because acute cystitis causes dysuria, urgency, and frequency but does not explain the high fever, chills, and markedly tender prostate; moreover, a urinary infection in a man is not classified as uncomplicated cystitis."
            },
            {
              "id": "B",
              "text": "Option B: Acute pyelonephritis is inappropriate because pyelonephritis typically causes fever with flank pain and costovertebral angle tenderness rather than marked prostatic tenderness."
            },
            {
              "id": "C",
              "text": "Option C: Acute epididymitis causes unilateral scrotal pain and tenderness localized to the epididymis rather than perineal pain and prostate tenderness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Acute uncomplicated cystitis is inappropriate because acute cystitis causes dysuria, urgency, and frequency but does not explain the high fever, chills, and markedly tender prostate; moreover, a urinary infection in a man is not classified as uncomplicated cystitis."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Chronic bacterial prostatitis typically presents with recurrent urinary tract infections or chronic pelvic symptoms rather than an abrupt febrile illness."
            },
            {
              "id": "B",
              "text": "Option B: Acute pyelonephritis is inappropriate because pyelonephritis typically causes fever with flank pain and costovertebral angle tenderness rather than marked prostatic tenderness."
            },
            {
              "id": "C",
              "text": "Option C: Acute epididymitis causes unilateral scrotal pain and tenderness localized to the epididymis rather than perineal pain and prostate tenderness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Chronic bacterial prostatitis typically presents with recurrent urinary tract infections or chronic pelvic symptoms rather than an abrupt febrile illness."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Benign prostatic hyperplasia with acute urinary retention is inappropriate because benign prostatic hyperplasia can cause hesitancy and retention, but it does not explain an abrupt high fever, shaking chills, pyuria, nitrites, and an exquisitely tender warm prostate. BPH is a predisposing obstructive condition rather than the principal acute diagnosis."
            },
            {
              "id": "B",
              "text": "Option B: Acute pyelonephritis is inappropriate because pyelonephritis typically causes fever with flank pain and costovertebral angle tenderness rather than marked prostatic tenderness."
            },
            {
              "id": "C",
              "text": "Option C: Acute epididymitis causes unilateral scrotal pain and tenderness localized to the epididymis rather than perineal pain and prostate tenderness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Benign prostatic hyperplasia with acute urinary retention is inappropriate because benign prostatic hyperplasia can cause hesitancy and retention, but it does not explain an abrupt high fever, shaking chills, pyuria, nitrites, and an exquisitely tender warm prostate. BPH is a predisposing obstructive condition rather than the principal acute diagnosis."
        },
        "G": {
          "prompt": "Which feature of option G should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Gonococcal urethritis typically causes urethral discharge and urethral symptoms. The absence of discharge and the presence of a markedly enlarged, warm, exquisitely tender prostate localize the infection to the prostate."
            },
            {
              "id": "B",
              "text": "Option B: Acute pyelonephritis is inappropriate because pyelonephritis typically causes fever with flank pain and costovertebral angle tenderness rather than marked prostatic tenderness."
            },
            {
              "id": "C",
              "text": "Option C: Acute epididymitis causes unilateral scrotal pain and tenderness localized to the epididymis rather than perineal pain and prostate tenderness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Gonococcal urethritis typically causes urethral discharge and urethral symptoms. The absence of discharge and the presence of a markedly enlarged, warm, exquisitely tender prostate localize the infection to the prostate."
        },
        "H": {
          "prompt": "Which feature of option H should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A perirectal abscess can cause fever and deep perineal pain, but it would not account as well for nitrite-positive pyuria and a diffusely enlarged, warm, exquisitely tender prostate."
            },
            {
              "id": "B",
              "text": "Option B: Acute pyelonephritis is inappropriate because pyelonephritis typically causes fever with flank pain and costovertebral angle tenderness rather than marked prostatic tenderness."
            },
            {
              "id": "C",
              "text": "Option C: Acute epididymitis causes unilateral scrotal pain and tenderness localized to the epididymis rather than perineal pain and prostate tenderness."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A perirectal abscess can cause fever and deep perineal pain, but it would not account as well for nitrite-positive pyuria and a diffusely enlarged, warm, exquisitely tender prostate."
        }
      }
    },
    {
      "externalId": "step3-urology-prostate-cancer-age-risk-941",
      "expectedHashes": {
        "ranaze_step3_uat": "eeeb18ca578bb4c1cd81819541f4b20efce40fca855a99a2de9a86d86994ab30",
        "ranaze_step3_prd": "eeeb18ca578bb4c1cd81819541f4b20efce40fca855a99a2de9a86d86994ab30"
      },
      "replacement": {
        "B": {
          "prompt": "Which feature of option B should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "History of benign prostatic hyperplasia is inappropriate because benign prostatic hyperplasia and prostate cancer are common in older men but arise from different regions of the prostate, and BPH is not considered a premalignant condition."
            },
            {
              "id": "B",
              "text": "Option C: Remote family history in a second-degree relative is inappropriate because family history is most significant when a first-degree relative is affected, especially at a younger age. A maternal cousin diagnosed at age 78 is a weaker risk factor than advanced age."
            },
            {
              "id": "C",
              "text": "Option D: Long-term finasteride use is inappropriate because finasteride lowers intraprostatic dihydrotestosterone and is not a stronger risk factor for prostate cancer than age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "History of benign prostatic hyperplasia is inappropriate because benign prostatic hyperplasia and prostate cancer are common in older men but arise from different regions of the prostate, and BPH is not considered a premalignant condition."
        },
        "C": {
          "prompt": "Which feature of option C should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Remote family history in a second-degree relative is inappropriate because family history is most significant when a first-degree relative is affected, especially at a younger age. A maternal cousin diagnosed at age 78 is a weaker risk factor than advanced age."
            },
            {
              "id": "B",
              "text": "Option B: History of benign prostatic hyperplasia is inappropriate because benign prostatic hyperplasia and prostate cancer are common in older men but arise from different regions of the prostate, and BPH is not considered a premalignant condition."
            },
            {
              "id": "C",
              "text": "Option D: Long-term finasteride use is inappropriate because finasteride lowers intraprostatic dihydrotestosterone and is not a stronger risk factor for prostate cancer than age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Remote family history in a second-degree relative is inappropriate because family history is most significant when a first-degree relative is affected, especially at a younger age. A maternal cousin diagnosed at age 78 is a weaker risk factor than advanced age."
        },
        "D": {
          "prompt": "Which feature of option D should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Long-term finasteride use is inappropriate because finasteride lowers intraprostatic dihydrotestosterone and is not a stronger risk factor for prostate cancer than age."
            },
            {
              "id": "B",
              "text": "Option B: History of benign prostatic hyperplasia is inappropriate because benign prostatic hyperplasia and prostate cancer are common in older men but arise from different regions of the prostate, and BPH is not considered a premalignant condition."
            },
            {
              "id": "C",
              "text": "Option C: Remote family history in a second-degree relative is inappropriate because family history is most significant when a first-degree relative is affected, especially at a younger age. A maternal cousin diagnosed at age 78 is a weaker risk factor than advanced age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Long-term finasteride use is inappropriate because finasteride lowers intraprostatic dihydrotestosterone and is not a stronger risk factor for prostate cancer than age."
        },
        "E": {
          "prompt": "Which feature of option E should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "A sedentary occupation is not a major established risk factor for prostate cancer."
            },
            {
              "id": "B",
              "text": "Option B: History of benign prostatic hyperplasia is inappropriate because benign prostatic hyperplasia and prostate cancer are common in older men but arise from different regions of the prostate, and BPH is not considered a premalignant condition."
            },
            {
              "id": "C",
              "text": "Option C: Remote family history in a second-degree relative is inappropriate because family history is most significant when a first-degree relative is affected, especially at a younger age. A maternal cousin diagnosed at age 78 is a weaker risk factor than advanced age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "A sedentary occupation is not a major established risk factor for prostate cancer."
        },
        "F": {
          "prompt": "Which feature of option F should have ruled it out in this case?",
          "choices": [
            {
              "id": "A",
              "text": "Elevated serum prostate-specific antigen concentration is inappropriate because an elevated PSA concentration can prompt evaluation for prostate cancer but is not a predisposing factor that causes or increases susceptibility to the disease. PSA may also be elevated with benign prostatic hyperplasia or prostatic inflammation. In this patient, advanced age is the strongest listed predisposing factor."
            },
            {
              "id": "B",
              "text": "Option B: History of benign prostatic hyperplasia is inappropriate because benign prostatic hyperplasia and prostate cancer are common in older men but arise from different regions of the prostate, and BPH is not considered a premalignant condition."
            },
            {
              "id": "C",
              "text": "Option C: Remote family history in a second-degree relative is inappropriate because family history is most significant when a first-degree relative is affected, especially at a younger age. A maternal cousin diagnosed at age 78 is a weaker risk factor than advanced age."
            }
          ],
          "correctChoiceId": "A",
          "teachingPoint": "Elevated serum prostate-specific antigen concentration is inappropriate because an elevated PSA concentration can prompt evaluation for prostate cancer but is not a predisposing factor that causes or increases susceptibility to the disease. PSA may also be elevated with benign prostatic hyperplasia or prostatic inflammation. In this patient, advanced age is the strongest listed predisposing factor."
        }
      }
    }
  ]
}