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Question Reference Reviews

This ledger records verification references for questions when the Questions API schema cannot store question-level source metadata. See the verification policy in README.md.

step3-biostatistics-diagnostic-threshold-sensitivity-specificity-3976

  • Source: Appendix: Test Performance Metrics
  • Publisher: National Center for Biotechnology Information
  • Supports: Raising the positive cutoff of a continuous test decreases sensitivity and increases specificity.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-cardiovascular-new-hypertension-3101

  • Source: Hypertension in Adults: Screening
  • Publisher: U.S. Preventive Services Task Force
  • Supports: Adults should be screened with office blood pressure measurement, but a positive screen should be confirmed with validated ambulatory or home blood pressure monitoring before treatment is started.
  • Source: Home Blood Pressure Monitoring
  • Publisher: American Heart Association
  • Supports: Home monitoring can confirm a hypertension diagnosis; repeated measurements over time are more informative than one elevated reading.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-infectious-bacterial-meningitis-3001

  • Source: WHO guidelines on meningitis diagnosis, treatment and care
  • Publisher: World Health Organization
  • Supports: Acute community-acquired bacterial meningitis requires prompt intravenous antibiotic treatment. Ceftriaxone or cefotaxime is first-line, with vancomycin added where resistant pneumococci are a concern; adjunctive dexamethasone should be given with the first antibiotic dose in non-epidemic settings.
  • Source: CDC Public Health Image Library: Streptococcus pneumoniae
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Streptococcus pneumoniae appears as gram-positive, lancet-shaped diplococci on Gram stain.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pulmonary-endobronchial-obstruction-5714

  • Source: Pediatric Bronchoscopy Guidelines
  • Publisher: Archivos de Bronconeumologia
  • Supports: Persistent or recurrent localized pulmonary opacities can reflect an unrecognized endobronchial foreign body and warrant airway evaluation.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-obgyn-antiphospholipid-syndrome-5862

step3-cardiology-vasospastic-angina-3827

  • Source: 2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease
  • Publisher: American Heart Association and American College of Cardiology
  • Supports: Nitrate-responsive rest angina, especially between night and early morning, supports suspected vasospastic angina; definitive diagnosis also requires transient ischemic ECG changes or documented coronary spasm.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-biostatistics-odds-ratio-confidence-interval-417

  • Source: Analyzing and Interpreting Data
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Case-control studies use odds ratios, and the null hypothesis is not rejected when a 95% confidence interval includes the null association value of 1.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pediatrics-congenital-cmv-638

  • Source: Clinical Overview of CMV and Congenital CMV
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Congenital CMV is confirmed by PCR testing of saliva, urine, or blood within the first 2-3 weeks of life; urine testing confirms a positive saliva screen and distinguishes congenital from postnatal infection.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-epidemiology-dose-response-causality-431

  • Source: Analyzing and Interpreting Data
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Increasing outcome risk with increasing exposure is a dose-response relationship, and evidence of this gradient adds weight to causal inference.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-neurology-papilledema-neuroimaging-438

  • Source: ACR Appropriateness Criteria: Headache
  • Publisher: American College of Radiology
  • Supports: Papilledema is a red flag for intracranial hypertension, and noncontrast head CT can promptly evaluate secondary causes such as mass, edema, or hydrocephalus before lumbar puncture.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pediatrics-abusive-head-trauma-ct-447

  • Source: Abusive Head Trauma in Infants and Children: Technical Report
  • Publisher: American Academy of Pediatrics
  • Supports: Head CT is the acute imaging modality of choice for cranial and intracranial injury in children with neurologic symptoms and concern for abuse; children age 2 years or younger also require a skeletal survey.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-ethics-decision-making-capacity-521

  • Source: Decisions for Adult Patients Who Lack Capacity
  • Publisher: American Medical Association
  • Supports: When an adult lacks decision-making capacity, physicians should identify and work with the surrogate designated through a durable power of attorney for health care; ethics consultation is reserved for absent, disputed, or inappropriate surrogate decision-making.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-biostatistics-screening-snout-412

step3-biostatistics-test-characteristics-486

  • Source: Performance Measures: Assessment of Cancer Screening
  • Publisher: National Center for Biotechnology Information
  • Supports: Sensitivity, specificity, PPV, and NPV derive from the diagnostic 2x2 table, and PPV can remain low for a rare disease despite high sensitivity and specificity.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-preventive-care-smoking-cessation-593

  • Source: Tobacco Smoking Cessation in Adults: Interventions
  • Publisher: U.S. Preventive Services Task Force
  • Supports: Clinicians should ask adults about tobacco use, advise cessation, and provide behavioral interventions and FDA-approved pharmacotherapy to nonpregnant adults who smoke.
  • Source: Colorectal Cancer Screening
  • Publisher: U.S. Preventive Services Task Force
  • Supports: Average-risk colorectal cancer screening begins at age 45.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pediatrics-kawasaki-coronary-aneurysm-701

  • Source: Update on Diagnosis and Management of Kawasaki Disease
  • Publisher: American Heart Association
  • Supports: Kawasaki disease can cause coronary artery dilation and aneurysms; coronary Z-score assessment and ongoing cardiac imaging guide risk assessment and follow-up.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-heartfailure-aldosterone-antagonist-884

  • Source: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
  • Publisher: American Heart Association, American College of Cardiology, and Heart Failure Society of America
  • Supports: An MRA is recommended to reduce morbidity and mortality in symptomatic HFrEF when eGFR is greater than 30 mL/min/1.73 m2 and potassium is below 5.0 mEq/L.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-gastroenterology-peptic-ulcer-prognosis-905

  • Source: ACG Guideline on Treatment of Helicobacter pylori
  • Publisher: American College of Gastroenterology
  • Supports: H. pylori infection should be treated and eradication confirmed at least 4 weeks after antibiotic therapy, with PPIs held before testing.
  • Source: The Role of Endoscopy in Peptic Ulcer Disease
  • Publisher: American Society for Gastrointestinal Endoscopy
  • Supports: Surveillance endoscopy for a gastric ulcer is individualized based on clinical and endoscopic circumstances rather than universally required.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-infectious-disease-antibiotic-stewardship-viral-uri-962

  • Source: Outpatient Clinical Care for Adults: Antibiotic Prescribing
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Antibiotics are not recommended for nonspecific viral upper respiratory infections, and outpatient evaluation should distinguish syndromes requiring antibacterial treatment from self-limited viral illness.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-musculoskeletal-occult-hip-fracture-mri-1007

  • Source: ACR Appropriateness Criteria: Acute Hip Pain
  • Publisher: American College of Radiology
  • Supports: When traumatic hip fracture is suspected despite negative or indeterminate radiographs, MRI without contrast and CT without contrast are appropriate next imaging studies.
  • Source: NICE Hip Fracture Management
  • Publisher: National Institute for Health and Care Excellence
  • Supports: Offer MRI for suspected occult hip fracture after negative x-rays; consider CT when MRI is unavailable within 24 hours or contraindicated.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pediatrics-jia-sports-participation-1134

  • Source: Exercise and Arthritis
  • Publisher: American College of Rheumatology
  • Supports: Exercise is recommended for juvenile idiopathic arthritis and can be individualized with physical or occupational therapy when modification is needed.
  • Source: 2021 ACR JIA Guideline: Nonpharmacologic Therapies
  • Publisher: American College of Rheumatology
  • Supports: Physical and occupational therapy are conditionally recommended in JIA but are supportive interventions rather than universal prerequisites for activity.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-psychiatry-acute-mania-antipsychotic-1208

step3-dermatology-acne-comedonal-initial-1209

  • Source: Acne Clinical Guideline
  • Publisher: American Academy of Dermatology
  • Supports: Current acne guidelines recommend topical retinoids as an effective topical therapy and recommend limiting systemic antibiotic use.
  • Source: Acne: Diagnosis and Treatment
  • Publisher: American Academy of Dermatology
  • Supports: Topical retinoids, including adapalene, clear pores and treat blackheads and whiteheads, supporting their use for isolated comedonal acne.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-infectious-bat-rabies-pep-1847

  • Source: Preventing Rabies from Bats
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Bat bites can be difficult to detect; public health or animal control should coordinate safe capture and rabies testing of a bat found in a home.
  • Source: Human Rabies Prevention: ACIP Recommendations
  • Publisher: Centers for Disease Control and Prevention
  • Supports: A bat found with an unattended child can constitute a potential exposure, but prophylaxis is unnecessary when the captured bat tests negative. The 10-day observation rule applies to dogs, cats, and ferrets.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-geriatrics-unintentional-weight-loss-social-isolation-2314

  • Source: Choosing Wisely
  • Publisher: American Geriatrics Society, Health in Aging Foundation
  • Supports: For anorexia or cachexia in older adults, clinicians should optimize social supports, provide appealing food and feeding assistance, and address contributing medications rather than routinely prescribing appetite stimulants or supplements.
  • Source: Unintentional Weight Loss in Older Adults
  • Publisher: American Academy of Family Physicians
  • Supports: Clinically significant weight loss requires an initial evaluation; social isolation can reduce intake, and treatment should address social support and the eating environment. Mirtazapine lacks evidence when used solely for weight loss and can cause adverse effects in older adults.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-cardiovascular-atrial-fibrillation-stroke-prevention-5172

  • Source: 2023 ACC/AHA/ACCP/HRS Guideline for Atrial Fibrillation
  • Publisher: American College of Cardiology, American Heart Association, American College of Chest Physicians, and Heart Rhythm Society
  • Supports: Anticoagulation is recommended for men with atrial fibrillation and CHA2DS2-VASc score of at least 2; direct oral anticoagulants are preferred in the absence of moderate-to-severe rheumatic mitral stenosis or a mechanical valve, and aspirin is not an acceptable substitute for anticoagulation.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-obgyn-abortion-complications-counseling-6815

  • Source: Abortion Care
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: First-trimester abortion is safe and effective; vaginal bleeding and cramping are expected, major complications are rare, and abortion does not increase infertility risk.
  • Source: Abortion Care
  • Publisher: Royal College of Obstetricians and Gynaecologists
  • Supports: Bleeding and abdominal cramping occur with both medical and procedural abortion, and patients should receive anticipatory guidance about expected bleeding and warning symptoms.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pediatrics-sports-clearance-innocent-murmur-1427

  • Source: Heart Murmurs in Children: Evaluation and Management
  • Publisher: American Academy of Family Physicians
  • Supports: In a child older than 2 years, disappearance of a murmur with standing strongly supports an innocent murmur; sports clearance is appropriate when history and examination are otherwise benign.
  • Source: The Preparticipation Sports Evaluation
  • Publisher: American Academy of Family Physicians
  • Supports: Athletes with well-controlled asthma can participate safely and should have a rescue inhaler available; routine pulmonary function testing is not required solely for clearance in an asymptomatic athlete with established controlled asthma.
  • Source: Heart Murmurs
  • Publisher: American Heart Association
  • Supports: Children with innocent murmurs do not require activity limitation.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-immunization-mmr-transient-arthralgia-615

  • Source: MMR Vaccine Safety
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Joint pain or stiffness occurs in up to one-quarter of susceptible postpubertal females, generally begins 1 to 3 weeks after MMR vaccination, is usually mild, lasts about 2 days, and rarely recurs.
  • Source: Pink Book, Chapter 20: Rubella
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Arthralgia after MMR vaccination is associated with the rubella component and occurs much more often in adult women than in children or men.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-integumentary-contaminated-laceration-delayed-closure-2841

  • Source: Clinical Guidance for Wound Management to Prevent Tetanus
  • Publisher: Centers for Disease Control and Prevention
  • Supports: A soil-contaminated wound is a dirty wound; a patient with unknown tetanus vaccination history should receive a tetanus-containing vaccine and tetanus immune globulin in addition to wound cleaning and debridement.
  • Source: Skin Lacerations
  • Publisher: MSD Manual Professional Edition
  • Supports: Delayed primary closure is appropriate for significantly contaminated wounds, particularly those containing organic debris; initial care includes thorough exploration, debridement, and loose moist-gauze packing followed by reassessment for closure.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-tetanus-prophylaxis-001

  • Source: Clinical Guidance for Wound Management to Prevent Tetanus
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Puncture wounds and wounds containing soil are dirty or major wounds. Patients with unknown vaccination history require a tetanus toxoid-containing vaccine, and those with dirty or major wounds also require tetanus immune globulin for immediate passive protection.
  • Source: Pink Book, Chapter 21: Tetanus
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Patients with non-clean wounds and unknown or fewer than three prior tetanus vaccine doses should receive both vaccine and tetanus immune globulin; Tdap is preferred when prior Tdap history is unknown.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-derm-alopecia-areata-001

  • Source: Alopecia Areata: Diagnosis and Treatment
  • Publisher: American Academy of Dermatology
  • Supports: Intralesional corticosteroid injections are considered the most effective treatment for adults with a few patches of alopecia areata; hair regrowth is often seen within approximately 3 months when treatment works.
  • Source: Alopecia Areata: Signs and Symptoms
  • Publisher: American Academy of Dermatology
  • Supports: Alopecia areata commonly presents with sudden round or oval smooth patches of nonscarring hair loss without scalp irritation.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-cardiology-pci-restenosis-001

step3-gi-barrett-gerd-001

  • Source: Barrett's Esophagus
  • Publisher: American College of Gastroenterology
  • Supports: Most patients with Barrett esophagus receive proton pump inhibitor therapy; antireflux surgery is used for GERD indications rather than as a cancer-prevention treatment, and nondysplastic Barrett esophagus is managed with surveillance rather than eradication therapy.
  • Source: Acid Reflux/GERD
  • Publisher: American College of Gastroenterology
  • Supports: Proton pump inhibitors and lifestyle measures are effective GERD therapy; objective reflux testing is particularly useful when symptoms are not controlled or antireflux surgery is being considered.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-gi-cdiff-complication-001

  • Source: C. diff: Facts for Clinicians
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Recognized severe complications of C. difficile infection include toxic megacolon, colonic perforation, sepsis, and death.
  • Source: SHEA/IDSA Clinical Practice Guideline for C. difficile Infection
  • Publisher: Infectious Diseases Society of America and Society for Healthcare Epidemiology of America
  • Supports: Fulminant C. difficile infection may be characterized by hypotension or shock, ileus, or megacolon; megacolon and perforation may require urgent surgical management.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-rheumatology-cppd-acute-treatment-734

  • Source: Calcium Pyrophosphate Deposition
  • Publisher: American College of Rheumatology
  • Supports: Acute CPP crystal arthritis may be treated with joint aspiration and glucocorticoid injection or systemic anti-inflammatory therapy including NSAIDs, oral glucocorticoids, or colchicine.
  • Source: Calcium Pyrophosphate Deposition Disease
  • Publisher: MSD Manual Professional Edition
  • Supports: Colchicine is an accepted treatment for acute CPP arthritis flares; NSAIDs and glucocorticoids are alternatives selected according to the number of affected joints and patient-specific contraindications.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-infectious-tuberculosis-screening-conversion-237

  • Source: Clinical Testing Guidance for Tuberculosis: Tuberculin Skin Test
  • Publisher: Centers for Disease Control and Prevention
  • Supports: A positive tuberculin skin test requires evaluation for TB disease; the result must be interpreted according to exposure and progression risk.
  • Source: ATS/CDC/IDSA Diagnosis of Tuberculosis Guideline
  • Publisher: American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America
  • Supports: Active TB is excluded by symptom assessment and chest radiography; respiratory sampling follows when symptoms or radiographic abnormalities suggest pulmonary disease. Confirmatory testing is mainly advised for an unexpected positive result in a person unlikely to be infected.
  • Source: CDC Contact Investigation Recommendations
  • Publisher: Centers for Disease Control and Prevention and National Tuberculosis Controllers Association
  • Supports: TST conversion is conventionally defined by an increase of at least 10 mm within 2 years.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-gastro-sbp-saag-241

  • Source: Recognition and Management of Spontaneous Bacterial Peritonitis
  • Publisher: University of Washington Hepatitis C Online
  • Supports: Ascitic fluid PMN count of at least 250 cells/mm3 warrants prompt empiric antibiotics; community-acquired SBP is treated with intravenous cefotaxime or a similar third-generation cephalosporin, whereas nosocomial infection may require broader therapy.
  • Source: AASLD: Why Timing Matters, Paracentesis on Admission
  • Publisher: American Association for the Study of Liver Diseases
  • Supports: In a patient with cirrhosis and ascites, an ascitic PMN count of at least 250 cells/uL carries a high likelihood of SBP and should prompt antibiotic treatment without waiting for culture results.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-cardiovascular-thiazide-followup-251

  • Source: 2025 High Blood Pressure Guideline: Top Things to Know
  • Publisher: American Heart Association and American College of Cardiology
  • Supports: Stage 2 hypertension is preferably treated with two first-line agents; home blood pressure monitoring and frequent follow-up are important while therapy is being adjusted, and a potassium-rich DASH-style diet is recommended when clinically appropriate.
  • Source: Chlorthalidone Prescribing Information
  • Publisher: U.S. National Library of Medicine DailyMed
  • Supports: Chlorthalidone can cause dose-related potassium reduction; electrolytes should be checked periodically, dose titration should follow a suitable therapeutic trial, and elderly patients should generally begin at the low end of the dose range.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-psych-acute-psychosis-261

  • Source: Adult Psychiatric Emergencies
  • Publisher: American College of Emergency Physicians
  • Supports: Psychosis and homicidal or violent behavior are psychiatric emergencies requiring risk stratification, acute treatment, and a safe disposition rather than routine outpatient follow-up.
  • Source: Crisis Services: Meeting Needs, Saving Lives
  • Publisher: Substance Abuse and Mental Health Services Administration
  • Supports: Acute psychiatric symptoms may require inpatient stabilization; risk of injury to others is a common civil-commitment criterion, although specific involuntary-hold procedures vary by jurisdiction.
  • Source: What Is Schizophrenia?
  • Publisher: Substance Abuse and Mental Health Services Administration
  • Supports: Hospitalization may be needed during a severe schizophrenia episode to ensure safety and stabilization.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pulmonary-copd-niv-271

  • Source: GOLD 2026 Report
  • Publisher: Global Initiative for Chronic Obstructive Lung Disease
  • Supports: NIV is the initial ventilatory mode for hospitalized COPD exacerbations with acute respiratory failure and is indicated with respiratory acidosis, including PaCO2 at least 45 mm Hg and pH at or below 7.35; it reduces intubation, complications, and mortality.
  • Source: ERS/ATS Guideline on NIV for Acute Respiratory Failure
  • Publisher: European Respiratory Society and American Thoracic Society
  • Supports: Bilevel NIV is strongly recommended for acute or acute-on-chronic respiratory acidosis due to COPD exacerbation, particularly at pH 7.25 to 7.35 when the patient is not immediately deteriorating and can be closely monitored with rapid access to intubation.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-supportive-care-acupuncture-cinv-2801

  • Source: Acupuncture PDQ, Health Professional Version
  • Publisher: National Cancer Institute
  • Supports: Among cancer-related symptoms studied, acupuncture has its most convincing evidence for chemotherapy-induced nausea and vomiting; it may be used as an adjunct to standard antiemetic therapy, although study quality and effects on specific nausea and vomiting outcomes vary.
  • Source: Nausea and Vomiting Related to Cancer Treatment PDQ
  • Publisher: National Cancer Institute
  • Supports: Persistent CINV can cause dehydration and nutritional depletion; management requires optimized pharmacologic antiemetics, dietary support, and selected nonpharmacologic adjuncts such as acupuncture or acupressure.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pulmonary-silicosis-progressive-fibrosis-2901

  • Source: Engineered Stone and Silicosis
  • Publisher: National Institute for Occupational Safety and Health
  • Supports: Engineered stone typically contains very high crystalline silica content, and respirable exposure during fabrication can cause irreversible occupational silicosis.
  • Source: Outbreak of Silicosis Among Engineered Stone Countertop Workers
  • Publisher: National Institute for Occupational Safety and Health
  • Supports: Silicosis is progressive, debilitating, incurable, and sometimes fatal; high-level engineered-stone exposure can produce severe disease.
  • Source: Severe Silicosis in Engineered Stone Fabrication Workers
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Progressive massive fibrosis is the most advanced form of silicosis and can cause continued lung-function decline requiring lung transplantation evaluation; silicosis also increases tuberculosis risk.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-neurology-tia-secondary-prevention-3201

  • Source: 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke
  • Publisher: American Heart Association/American Stroke Association
  • Supports: Eligible patients with disabling acute ischemic stroke deficits should receive rapid intravenous thrombolysis within 4.5 hours regardless of NIHSS score, whereas dual antiplatelet therapy is preferred for selected nondisabling events.
  • Source: 2021 Guideline for Prevention of Stroke in Patients With Stroke and TIA
  • Publisher: American Heart Association/American Stroke Association
  • Supports: Short-term dual antiplatelet therapy is recommended only for selected patients, including early-arriving minor ischemic stroke and high-risk transient ischemic attack; occult atrial-fibrillation monitoring is also appropriate when no other cause is identified.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-neuro-acute-dystonia-337

  • Source: Reglan injection prescribing information
  • Publisher: U.S. Food and Drug Administration
  • Supports: Metoclopramide can cause acute dystonic reactions within the first 24-48 hours, including torticollis, trismus, and oculogyric crisis; diphenhydramine or benztropine can treat the reaction, and metoclopramide should be discontinued when extrapyramidal symptoms develop.
  • Source: Treatment of acute adverse effects of antipsychotics
  • Publisher: Merck Manual Professional Edition
  • Supports: Acute dystonic reactions such as oculogyric crisis and torticollis are treated with intravenous or intramuscular diphenhydramine or benztropine.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-endocrine-diabetic-nephropathy-401

  • Source: Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes - 2026
  • Publisher: American Diabetes Association
  • Supports: In nonpregnant people with diabetes and hypertension, an ACE inhibitor or ARB is recommended when UACR is 30-299 mg/g and is strongly recommended with UACR at least 300 mg/g and/or eGFR below 60. Evidence does not establish kidney-outcome benefit for moderately increased albuminuria without hypertension, and abnormal UACR should be confirmed because of biological variability.
  • Source: ADA-KDIGO consensus report on diabetes management in CKD
  • Publisher: American Diabetes Association and Kidney Disease: Improving Global Outcomes
  • Supports: ACE inhibitor or ARB therapy is recommended and titrated to the highest tolerated dose in patients with diabetes, hypertension, and albuminuria.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-genitourinary-chronic-bacterial-prostatitis-302

  • Source: EAU Guidelines on Urological Infections: Bacterial Prostatitis
  • Publisher: European Association of Urology
  • Supports: Chronic bacterial prostatitis should receive culture-guided antimicrobial treatment; fluoroquinolones are recommended first-line for susceptible typical gram-negative pathogens and are generally given for 4-6 weeks because of their prostatic penetration.
  • Source: Fluoroquinolone safety reminder
  • Publisher: UK Medicines and Healthcare products Regulatory Agency
  • Supports: Fluoroquinolones can cause disabling, prolonged, or irreversible adverse effects and require patient counseling and prompt discontinuation if serious tendon, muscle, joint, peripheral nerve, or central nervous system symptoms develop.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-em-criticalcare-hypothermia-403

  • Source: AHA Special Circumstances of Resuscitation
  • Publisher: American Heart Association
  • Supports: Full resuscitation and rewarming should continue in life-threatening environmental hypothermia without an obviously lethal injury. Prognosis for extracorporeal rewarming should use the validated HOPE score, which includes age, sex, asphyxia, CPR duration, serum potassium, and core temperature; isolated clinical or laboratory findings should not determine futility.
  • Source: 2025 Special Circumstances Guidelines
  • Publisher: Resuscitation Council UK
  • Supports: In-hospital prognostication for successful rewarming after hypothermic cardiac arrest should be based on the HOPE score.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-obgyn-hellp-urgent-delivery-404

  • Source: Preeclampsia and High Blood Pressure During Pregnancy
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: HELLP syndrome is a medical emergency. Preeclampsia with severe features at or beyond 34 weeks should be managed in the hospital with maternal stabilization, seizure prophylaxis and blood-pressure treatment as indicated, followed by delivery once stable.
  • Source: ACOG overview: 7 Things to Know About Preeclampsia
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: HELLP requires immediate delivery; severe preeclampsia at or after 34 weeks generally warrants delivery, with antihypertensive medication and magnesium sulfate used during stabilization.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-endocrine-primary-aldosteronism-medical-therapy-506

  • Source: Primary Aldosteronism: Endocrine Society Clinical Practice Guideline
  • Publisher: Endocrine Society
  • Supports: Primary aldosteronism should receive aldosterone-specific therapy. Lifelong mineralocorticoid receptor antagonist treatment is appropriate for bilateral disease, unknown lateralization, patients who decline surgery, or those who are not surgical candidates; spironolactone is suggested because of cost and availability, with potassium, renal function, renin, and blood pressure monitored during titration.
  • Source: Primary Aldosteronism guideline full text
  • Publisher: Journal of Clinical Endocrinology & Metabolism
  • Supports: CT imaging cannot reliably determine functional lateralization. Patients who desire and are candidates for adrenalectomy generally require CT plus adrenal venous sampling before choosing surgical therapy.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-infectious-mrsa-pneumonia-linezolid-707

  • Source: ATS/IDSA Community-Acquired Pneumonia Guideline Executive Summary
  • Publisher: American Thoracic Society and Infectious Diseases Society of America
  • Supports: Recommended MRSA-active treatment options for hospitalized adults with community-acquired pneumonia include vancomycin or linezolid.
  • Source: ATS/IDSA HAP/VAP Guideline
  • Publisher: American Thoracic Society and Infectious Diseases Society of America
  • Supports: Confirmed MRSA pneumonia should be treated with vancomycin or linezolid; patient-specific factors such as renal function, blood counts, serotonergic medications, and cost can guide selection.
  • Source: Daptomycin prescribing information
  • Publisher: U.S. Food and Drug Administration
  • Supports: Daptomycin is not indicated for treatment of pneumonia.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-endocrine-new-diabetes-lipid-screen-842

  • Source: Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2026
  • Publisher: American Diabetes Association
  • Supports: Adults with diabetes aged 40-75 years without ASCVD should receive at least moderate-intensity statin therapy. A lipid profile establishes the baseline needed to assess LDL reduction, identify severe dyslipidemia, and monitor response and adherence after therapy begins.
  • Source: Comprehensive Medical Evaluation: Standards of Care in Diabetes - 2026
  • Publisher: American Diabetes Association
  • Supports: Adults with type 2 diabetes should also be assessed for metabolic liver fibrosis risk with FIB-4, which uses age, AST, ALT, and platelet count; therefore hepatic enzymes and CBC components should not be presented as categorically unnecessary distractors in an initial diabetes evaluation.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-neuro-missed-antiseizure-dose-316

  • Source: Levetiracetam Medication Guide
  • Publisher: U.S. National Library of Medicine DailyMed
  • Supports: A missed levetiracetam dose should be taken when remembered unless it is almost time for the next dose; in that case, the missed dose should be skipped and the next dose taken at the regular time without doubling.
  • Source: How and when to take levetiracetam
  • Publisher: National Health Service
  • Supports: For twice-daily levetiracetam, if fewer than 8 hours remain before the next dose, skip the missed dose and take the next dose normally; never take an extra dose to compensate.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-ethics-shared-decision-oncology-481

  • Source: Surgery to Reduce the Risk of Breast Cancer
  • Publisher: National Cancer Institute
  • Supports: Contralateral risk-reducing mastectomy lowers contralateral cancer incidence but is generally discouraged for average-risk patients because contralateral risk is low, complications may increase, and available evidence does not show reduced mortality; benefits and harms should be individualized and discussed.
  • Source: Mastectomy: Single vs. Double Mastectomy
  • Publisher: National Cancer Institute
  • Supports: Patients without a high-risk mutation or strong family history do not generally live longer after double rather than single mastectomy, but concerns about recurrence, surveillance, symmetry, body image, reconstruction, risks, and patient preferences should be discussed in shared decision-making.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-neuro-ischemic-stroke-supportive-bp-615

step3-urogynecology-stress-incontinence-pessary-612

  • Source: Urinary Incontinence
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: Stress urinary incontinence causes leakage with coughing, laughing, walking, running, or exercise; a fitted pessary can support the vaginal walls, bladder, and urethra and provide symptom relief without surgery.
  • Source: Pelvic Support Problems
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: Anterior vaginal wall prolapse results from weakened pelvic support; pessaries can be used for short- or long-term support and many patients obtain immediate relief, while pelvic floor exercises may also improve incontinence.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-cardiology-preop-ecg-incidental-552

  • Source: 2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery
  • Publisher: American Heart Association/American College of Cardiology
  • Supports: Routine resting ECG is not recommended for asymptomatic patients undergoing low-risk surgery; further evaluation is reasonable for new ECG abnormalities, not an unchanged chronic finding.
  • Source: 2024 AHA/ACC Perioperative Cardiovascular Management Guideline: Key Points
  • Publisher: American College of Cardiology
  • Supports: Patients with good functional capacity, low predicted perioperative risk, or a planned low-risk procedure should not undergo routine preoperative stress testing.
  • Media: Original ECG schematic created for this question; no third-party image was uploaded.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-psychiatry-late-life-depression-mirtazapine-714

  • Source: VA/DoD Clinical Practice Guideline: Management of Major Depressive Disorder
  • Publisher: U.S. Department of Veterans Affairs and Department of Defense
  • Supports: Major depressive disorder should be treated with evidence-based pharmacotherapy and/or psychotherapy selected according to clinical features, patient preferences, comorbidities, and adverse-effect profiles.
  • Source: Mirtazapine Prescribing Information
  • Publisher: U.S. National Library of Medicine DailyMed
  • Supports: Mirtazapine is indicated for major depressive disorder; common effects include somnolence, increased appetite, weight gain, and dizziness, which informs individualized use and monitoring in an older patient with insomnia and clinically significant weight loss.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-bone-health-osteoporosis-bisphosphonate-815

  • Source: Pharmacological Management of Osteoporosis in Postmenopausal Women
  • Publisher: Endocrine Society
  • Supports: Bisphosphonates are recommended as initial therapy for postmenopausal women at high fracture risk; raloxifene is limited to women at low DVT risk, menopausal hormone therapy is limited to selected younger women at low DVT risk, and calcitonin is reserved for patients unable to use preferred agents.
  • Source: Raloxifene Prescribing Information
  • Publisher: U.S. Food and Drug Administration
  • Supports: Raloxifene is contraindicated in women with an active or past history of venous thromboembolism, including deep venous thrombosis and pulmonary embolism.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-endocrine-dka-dextrose-potassium-916

  • Source: Hyperglycemic Crises in Adults With Diabetes: A Consensus Report
  • Publisher: American Diabetes Association and European Association for the Study of Diabetes
  • Supports: When glucose falls below 250 mg/dL during DKA treatment, add 5%-10% dextrose and reduce but continue intravenous insulin until ketonemia resolves; add potassium when serum potassium falls below 5.0 mmol/L to maintain 4-5 mmol/L, and reserve bicarbonate for severe acidosis with pH below 7.0.
  • Source: Hyperglycemic Crises in Adults With Diabetes: Full Consensus Report
  • Publisher: Diabetes Care via PubMed Central
  • Supports: DKA resolution requires beta-hydroxybutyrate below 0.6 mmol/L plus venous pH at least 7.3 or bicarbonate at least 18 mmol/L; glucose normalization alone is not sufficient to stop insulin.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-substance-use-alcohol-blackout-counseling-917

  • Source: Interrupted Memories: Alcohol-Induced Blackouts
  • Publisher: National Institute on Alcohol Abuse and Alcoholism
  • Supports: During an alcohol-induced blackout a person remains awake but cannot consolidate new memories; even one blackout is concerning, predicts increased risk of alcohol-related harms, and should prompt discussion and assessment of drinking behavior.
  • Source: Screening, Brief Intervention, and Referral to Treatment
  • Publisher: Substance Abuse and Mental Health Services Administration
  • Supports: Emergency departments are appropriate settings for validated substance-use screening, brief intervention for at-risk use, and referral for additional assessment or treatment when indicated.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-gastroenterology-splenic-infarction-post-sclerotherapy-918

  • Source: Splenic Abscess: A Possible Complication of Endoscopic Variceal Sclerotherapy
  • Publisher: PubMed-indexed case report
  • Supports: Splenic abscess is a reported rare complication of endoscopic variceal sclerotherapy, potentially related to bacteremia or retrograde portal venous thrombosis after the procedure.
  • Source: AAST Acute Care Surgery Curriculum: Splenic Abscess
  • Publisher: American Association for the Surgery of Trauma
  • Supports: CT establishes the diagnosis; initial treatment includes hospital admission and broad-spectrum antibiotics, with definitive source control by percutaneous drainage or splenectomy selected according to anatomy and clinical status.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-gynecology-pessary-vaginitis-919

  • Source: Vaginal Pessary Use and Management for Pelvic Organ Prolapse
  • Publisher: American Urogynecologic Society and Society of Urologic Nurses and Associates
  • Supports: AUGS identifies its joint clinical consensus statement as current guidance for pessary use, surveillance, and management of pessary-related complications.
  • Source: Updates in Pessary Care for Pelvic Organ Prolapse: A Narrative Review
  • Publisher: Journal of Clinical Medicine via PubMed Central
  • Supports: Pessary-associated discharge is common and does not necessarily indicate infection; pessary-related epithelial changes are classified by direct examination, and management may include cleaning, temporary removal, vaginal assessment, and treatment directed by the observed complication.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pulmonary-copd-exacerbation-bronchodilator-920

  • Source: Global Initiative for Chronic Obstructive Lung Disease 2026 Report
  • Publisher: Global Initiative for Chronic Obstructive Lung Disease
  • Supports: Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are the initial bronchodilators for an acute COPD exacerbation. Systemic corticosteroids improve recovery, and antibiotics are indicated when increased sputum purulence accompanies other cardinal symptoms or mechanical ventilation is required.
  • Source: Chronic Obstructive Pulmonary Disease in Over 16s: Diagnosis and Management
  • Publisher: National Institute for Health and Care Excellence
  • Supports: Acute exacerbation management includes increased short-acting bronchodilator therapy, controlled oxygen when needed, systemic corticosteroids for significant breathlessness, and antibiotics when sputum changes suggest a bacterial trigger.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-obgyn-tuboovarian-abscess-641

  • Source: Pelvic Inflammatory Disease: STI Treatment Guidelines
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Tubo-ovarian abscess is an indication for hospitalization and more than 24 hours of inpatient observation. Recommended parenteral therapy includes ceftriaxone, doxycycline, and metronidazole, with continued anaerobic coverage when an abscess is present.
  • Source: Pelvic Inflammatory Disease
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: PID can produce a tubo-ovarian abscess; antibiotics are the usual initial treatment, while selected abscesses may require a procedure or surgery.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-musculoskeletal-scoliosis-screen-422

  • Source: Adolescent Idiopathic Scoliosis: Screening
  • Publisher: U.S. Preventive Services Task Force
  • Supports: The forward bend test is commonly used to evaluate adolescents for scoliosis, a scoliometer can quantify trunk rotation, and an angle of 5-7 degrees commonly prompts radiography. The USPSTF concludes that evidence is insufficient to determine the benefits and harms of universal screening.
  • Source: Scoliosis
  • Publisher: Scoliosis Research Society
  • Supports: The Adams forward bend test reveals asymmetric rib or lumbar prominence and is the most frequently used clinical screening maneuver for scoliosis.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-ethics-geriatric-cataract-capacity-923

  • Source: Decisions for Adult Patients Who Lack Capacity
  • Publisher: American Medical Association Code of Medical Ethics
  • Supports: Patients should participate in decisions according to their decision-making capacity; a surrogate exercises authority when the patient lacks capacity for the decision, not merely because a cognitive disorder is present.
  • Source: Cataract Surgery
  • Publisher: National Eye Institute
  • Supports: Cataract surgery is considered when vision loss interferes with everyday activities such as reading; it is common, generally outpatient, and improves vision in most patients, although individualized risks must be discussed.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-obstetrics-initial-prenatal-blood-type-1024

  • Source: Routine Tests During Pregnancy
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: Initial prenatal laboratory testing includes maternal blood type and Rh status; early identification of Rh-negative patients and alloantibodies guides prophylaxis and monitoring.
  • Source: Screening for Fetal Chromosomal Abnormalities
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: Cell-free DNA is the most sensitive and specific screening test for common fetal aneuploidies and should be made available to all obstetric patients after counseling, regardless of baseline risk.
  • Source: Oocyte or Embryo Donation to Women of Advanced Reproductive Age
  • Publisher: American Society for Reproductive Medicine Ethics Committee
  • Supports: In donor-oocyte pregnancies, the incidence of age-related genetic abnormalities in offspring relates primarily to the age of the oocyte donor rather than the gestational carrier.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-urology-testicular-torsion-811

  • Source: AUA Medical Student Curriculum: The Acute Scrotum
  • Publisher: American Urological Association
  • Supports: Definitive treatment of testicular torsion is immediate scrotal exploration. The affected testis is detorsed and fixed if viable, and the contralateral testis undergoes orchiopexy because the bell-clapper deformity is assumed to be bilateral.
  • Source: Acute Scrotal Pain Clinical Pathway
  • Publisher: Johns Hopkins All Children's Hospital
  • Supports: Sudden severe pain with a high-riding or transverse testis and absent cremasteric reflex can establish torsion clinically and should prompt immediate surgical consultation; Doppler ultrasonography is used for equivocal cases.
  • Accessed: 2026-07-12
  • Reviewer: Codex

step3-pediatrics-hsp-prognosis-517

step3-pediatrics-asthma-environmental-control-388

  • Source: Global Strategy for Asthma Management and Prevention, 2025
  • Publisher: Global Initiative for Asthma
  • Supports: Parents and caregivers of children with asthma should be advised not to smoke or vape and not to permit smoking or vaping in rooms or vehicles used by their children; cessation support should be provided.
  • Source: Asthma and Secondhand Smoke
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Tobacco smoke is a common asthma trigger; families should not smoke or allow smoking in the home or car, and opening a window does not protect a child from secondhand smoke.
  • Source: Secondhand Tobacco Smoke and Indoor Air Quality
  • Publisher: U.S. Environmental Protection Agency
  • Supports: Secondhand smoke causes more frequent and severe asthma attacks in children, has no safe exposure level, and cannot be eliminated by ventilation or air cleaning.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-infectious-facial-cellulitis-cefazolin-929

  • Source: Clinical Guidance for Group A Streptococcal Cellulitis
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Nonpurulent cellulitis should receive an antibiotic active against streptococci; intravenous options for systemic infection include cefazolin.
  • Source: Practice Guidelines for Skin and Soft Tissue Infections
  • Publisher: Infectious Diseases Society of America
  • Supports: Moderate nonpurulent cellulitis requires systemic antibiotics; cefazolin covers streptococci and MSSA, while MRSA coverage is reserved for defined risk factors or severe infection.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-hematology-hemophilia-hemarthrosis-928

  • Source: WFH Guidelines for the Management of Hemophilia, 3rd Edition: Prophylaxis
  • Publisher: World Federation of Hemophilia
  • Supports: Children with severe hemophilia should receive early, regular prophylaxis; long-term prophylaxis reduces hemarthrosis, slows hemophilic arthropathy, and improves joint outcomes compared with episodic treatment.
  • Source: About Hemophilia
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Joint bleeding is a common manifestation of hemophilia and can cause chronic joint disease and pain; regular prophylaxis can prevent most bleeding episodes.
  • Source: Testing for Inhibitors and Hemophilia
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Factor VIII inhibitors are a separate serious treatment complication that can render replacement factor ineffective and warrant regular testing.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-cardiovascular-aaa-surveillance-930

  • Source: 2022 ACC/AHA Aortic Disease Guideline: Key Perspectives
  • Publisher: American College of Cardiology / American Heart Association
  • Supports: Men with an AAA measuring 4.0-4.9 cm should undergo annual surveillance; repair is recommended at 5.5 cm or for aneurysm-related symptoms.
  • Source: Patients with Abdominal Aortic Aneurysm
  • Publisher: Society for Vascular Surgery
  • Supports: AAA measuring 4.0-4.9 cm should receive surveillance imaging at 12-month intervals; vascular-surgery referral is recommended at diagnosis.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-gastrointestinal-bowel-obstruction-imaging-731

  • Source: ACR Appropriateness Criteria: Suspected Small-Bowel Obstruction
  • Publisher: American College of Radiology
  • Supports: CT abdomen and pelvis with intravenous contrast is preferred for acute suspected obstruction because it identifies the level, cause, bowel perfusion, and complications; oral contrast is unnecessary in high-grade SBO.
  • Source: ASGE Guideline on Colonic Volvulus and Acute Colonic Pseudo-Obstruction
  • Publisher: American Society for Gastrointestinal Endoscopy
  • Supports: Cross-sectional CT distinguishes volvulus, pseudo-obstruction, and other mechanical obstruction and has replaced plain radiography as the preferred diagnostic study for suspected sigmoid or cecal volvulus.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-preventive-cervical-screening-sexual-orientation-932

  • Source: Screening for Cervical Cancer
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: Under the 2026 ACOG/WPSI guidance, average-risk patients age 21-29 years should receive cervical cytology alone every 3 years.
  • Source: Women Who Have Sex with Women
  • Publisher: Centers for Disease Control and Prevention
  • Supports: HPV can be transmitted between female partners, and routine cervical cancer screening should be offered regardless of sexual orientation or practices.
  • Source: HPV Infection and Vaccination
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: HPV vaccination does not protect against all HPV types and does not remove the need for age-appropriate cervical cancer screening.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-cardiovascular-risk-smoking-841

  • Source: Tobacco Smoking Cessation in Adults: Interventions
  • Publisher: U.S. Preventive Services Task Force
  • Supports: Adults who smoke should receive behavioral interventions and FDA-approved pharmacotherapy; the net benefit of cessation treatment is substantial.
  • Source: Smoking and Cardiovascular Disease
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Smoking cessation improves cardiovascular health, with coronary heart disease risk falling sharply within 1-2 years after cessation.
  • Source: Aspirin Use to Prevent Cardiovascular Disease
  • Publisher: U.S. Preventive Services Task Force
  • Supports: For adults age 40-59 years with elevated cardiovascular risk, aspirin initiation is individualized because the average net benefit is small.
  • Source: Vitamin and Multivitamin Supplementation to Prevent CVD and Cancer
  • Publisher: U.S. Preventive Services Task Force
  • Supports: Evidence is insufficient to recommend multivitamins for preventing cardiovascular disease, and trials have not shown cardiovascular mortality benefit.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-cardiovascular-exercise-hdl-614

step3-musculoskeletal-lateral-ankle-sprain-935

  • Source: Lateral Ankle Ligament Sprains Clinical Practice Guideline
  • Publisher: Academy of Orthopaedic Physical Therapy / Journal of Orthopaedic & Sports Physical Therapy
  • Supports: Acute lateral ankle sprains should receive external support and progressive weight bearing; intermittent ice may be used with therapeutic exercise.
  • Source: ACR Appropriateness Criteria: Acute Trauma to the Ankle
  • Publisher: American College of Radiology
  • Supports: Ankle radiography is usually not appropriate when Ottawa ankle rules are negative, with no relevant bony tenderness and preserved four-step ambulation.
  • Source: Sprained Ankle
  • Publisher: American Academy of Orthopaedic Surgeons
  • Supports: Mild sprains are treated conservatively with early weight bearing, removable support when needed, and early functional rehabilitation.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-obstetrics-prenatal-cocaine-exposure-674

  • Source: Cocaine
  • Publisher: MotherToBaby / Organization of Teratology Information Specialists
  • Supports: Late prenatal cocaine exposure can be followed by irritability, tremors, stiffness, poor feeding, sleep disturbance, and hyperactivity; exposure also increases risks of low birth weight, prematurity, and placental abruption.
  • Source: Neonatal Drug Withdrawal
  • Publisher: American Academy of Pediatrics
  • Supports: Cocaine-exposed neonates can have irritability, hyperactivity, tremors, and feeding abnormalities, but a distinct stimulant abstinence syndrome is not clearly defined and findings may reflect residual drug effect.
  • Source: Management of Stillbirth
  • Publisher: American College of Obstetricians and Gynecologists
  • Supports: Maternal cocaine and tobacco use are important contributors to placental abruption and stillbirth risk.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-fetal-alcohol-earlyintervention-037

  • Source: Treatment of Fetal Alcohol Spectrum Disorders
  • Publisher: Centers for Disease Control and Prevention
  • Supports: Early intervention can improve development; infants and toddlers with fetal alcohol syndrome commonly qualify immediately without waiting for an established developmental delay.
  • Source: IDEA Regulation 34 CFR 303.21: Infant or Toddler with a Disability
  • Publisher: U.S. Department of Education
  • Supports: Part C eligibility includes diagnosed conditions with a high probability of developmental delay and specifically names fetal alcohol syndrome.
  • Source: IDEA Part C Early Intervention Program
  • Publisher: U.S. Department of Education
  • Supports: Part C provides coordinated, multidisciplinary, family-centered services for eligible children from birth through age 2 years.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-congenital-hypothyroidism-adoptedinfant-038

  • Source: Congenital Hypothyroidism: Screening and Management
  • Publisher: American Academy of Pediatrics
  • Supports: Confirmed congenital hypothyroidism requires prompt levothyroxine; treatment timing is critical for neurodevelopment, and imaging must never delay therapy.
  • Source: Congenital Hypothyroidism
  • Publisher: American Thyroid Association
  • Supports: Low free T4 with elevated TSH confirms primary congenital hypothyroidism; levothyroxine is standard treatment with frequent biochemical monitoring and pediatric endocrine follow-up.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-delirium-collateral-history-039

  • Source: Delirium: prevention, diagnosis and management
  • Publisher: National Institute for Health and Care Excellence
  • Supports: Recent changes or fluctuations suggesting delirium may be reported by a relative or carer; identified cases require formal delirium assessment and evaluation and management of contributing causes.
  • Source: Dementia: assessment, management and support
  • Publisher: National Institute for Health and Care Excellence
  • Supports: Initial cognitive assessment includes history from the patient and, when possible, someone who knows the patient well to characterize cognition, behavior, and effects on daily life.
  • Source: Syphilis: STI Treatment Guidelines
  • Publisher: Centers for Disease Control and Prevention
  • Supports: A reactive nontreponemal test such as RPR requires confirmation with a treponemal test; a single serologic test is insufficient for diagnosis.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-pediatrics-physiologic-anemia-infancy-940

  • Source: Well Care for Formerly Preterm Infants
  • Publisher: American Academy of Pediatrics
  • Supports: Physiologic anemia in term infants reaches a hemoglobin nadir at approximately 8-12 weeks, later and at a higher level than in preterm infants.
  • Source: Perinatal Anemia
  • Publisher: MSD Manual Professional Edition
  • Supports: Increased oxygenation after birth suppresses erythropoietin and erythropoiesis; the shorter neonatal erythrocyte lifespan also contributes to the fall over the first 2-3 months, followed by recovery without treatment in healthy term infants.
  • Source: Pathophysiology of Anemia During the Neonatal Period, Including Anemia of Prematurity
  • Publisher: NeoReviews / U.S. National Library of Medicine
  • Supports: Healthy term infants are generally asymptomatic as hemoglobin falls to its physiologic nadir at approximately 8-10 weeks and then gradually rises.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-oncology-metastatic-adenocarcinoma-prognosis-941

  • Source: Cancer of Unknown Primary Treatment (PDQ), Health Professional Version
  • Publisher: National Cancer Institute
  • Supports: CUP generally has poor prognosis, with approximately 30% of patients alive at 1 year; adenocarcinoma histology, older age, hepatic involvement, poor performance status, and elevated LDH are associated with worse survival.
  • Source: SEOM-GECOD Clinical Guideline for Cancer of Unknown Primary, Update 2025
  • Publisher: Spanish Society of Medical Oncology / Springer Nature
  • Supports: Approximately 80% of CUP cases belong to an unfavorable subgroup with median overall survival of roughly 6-12 months; performance status and LDH further refine prognosis, and selected favorable clinicopathologic subsets require separate management.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-geriatrics-depression-weightloss-mirtazapine-942

  • Source: Unintentional Weight Loss in Older Adults
  • Publisher: American Academy of Family Physicians
  • Supports: Mirtazapine can cause appetite increase and weight gain when used to treat depression, but evidence does not support prescribing it solely as an appetite stimulant; somnolence and dizziness may increase fall risk.
  • Source: Choosing Wisely
  • Publisher: American Geriatrics Society / Health in Aging Foundation
  • Supports: Avoid prescription appetite stimulants for nonspecific anorexia in older adults; megestrol has minimal benefit and increases thrombotic events, fluid retention, and death, whereas mirtazapine may increase appetite when it is being used for coexisting depression.
  • Source: American Geriatrics Society 2023 Updated AGS Beers Criteria
  • Publisher: American Geriatrics Society
  • Supports: Megestrol should be avoided in older adults because its effect on weight is minimal and it increases thrombotic events and possibly death.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-postoperative-fluid-overload-diuresis-943

  • Source: Acute Heart Failure: Diagnosis and Management
  • Publisher: National Institute for Health and Care Excellence
  • Supports: Acute pulmonary congestion should be treated with intravenous loop diuretics, with close monitoring of renal function, weight, and urine output; ventilatory support is considered when severe respiratory failure or persistent distress is present.
  • Source: 2013 ACCF/AHA Guideline for the Management of Heart Failure, Executive Summary
  • Publisher: American College of Cardiology / American Heart Association
  • Supports: Hospitalized patients with significant fluid overload should receive prompt intravenous loop diuretics, with serial assessment of urine output, congestion, renal function, and electrolytes.
  • Source: Diuretic Therapy for Patients With Heart Failure
  • Publisher: American College of Cardiology
  • Supports: Loop diuretic dosing is guided by volume status and decongestion; renal function changes must be interpreted in the context of persistent congestion.
  • Accessed: 2026-07-13
  • Reviewer: Codex

step3-cardiovascular-white-coat-hypertension-device-check-944

  • Source: Home Blood Pressure Monitoring
  • Publisher: American Heart Association
  • Supports: Patients should use a validated upper-arm device with the correct cuff size, bring it to clinic so accuracy and technique can be checked, and use standardized preparation, positioning, and repeated measurements.
  • Source: Device Calibration Test for Self-Measured Blood Pressure Devices
  • Publisher: American Medical Association
  • Supports: When home results are unreasonably discrepant from office results, compare sequential readings from the patient's device and a validated office device after confirming proper preparation, positioning, and technique.
  • Source: Harmonization of ACC/AHA and ESC/ESH Blood Pressure Guidelines
  • Publisher: American College of Cardiology
  • Supports: Accurate measurement using validated devices and multiple readings is foundational; home or ambulatory monitoring is recommended to identify and confirm white-coat and masked blood pressure patterns.
  • Accessed: 2026-07-13
  • Reviewer: Codex
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