1354 lines
81 KiB
Markdown
1354 lines
81 KiB
Markdown
# Question Reference Reviews
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This ledger records verification references for questions when the Questions API
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schema cannot store question-level source metadata. See the verification policy
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in `README.md`.
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## step3-biostatistics-diagnostic-threshold-sensitivity-specificity-3976
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- Source: [Appendix: Test Performance Metrics](https://www.ncbi.nlm.nih.gov/sites/books/NBK98249/pdf/Bookshelf_NBK98249.pdf)
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- Publisher: National Center for Biotechnology Information
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- Supports: Raising the positive cutoff of a continuous test decreases
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sensitivity and increases specificity.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-cardiovascular-new-hypertension-3101
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- Source: [Hypertension in Adults: Screening](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening)
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- Publisher: U.S. Preventive Services Task Force
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- Supports: Adults should be screened with office blood pressure measurement,
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but a positive screen should be confirmed with validated ambulatory or home
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blood pressure monitoring before treatment is started.
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- Source: [Home Blood Pressure Monitoring](https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home)
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- Publisher: American Heart Association
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- Supports: Home monitoring can confirm a hypertension diagnosis; repeated
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measurements over time are more informative than one elevated reading.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-infectious-bacterial-meningitis-3001
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- Source: [WHO guidelines on meningitis diagnosis, treatment and care](https://www.who.int/publications/i/item/9789240108042)
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- Publisher: World Health Organization
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- Supports: Acute community-acquired bacterial meningitis requires prompt
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intravenous antibiotic treatment. Ceftriaxone or cefotaxime is first-line,
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with vancomycin added where resistant pneumococci are a concern; adjunctive
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dexamethasone should be given with the first antibiotic dose in non-epidemic
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settings.
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- Source: [CDC Public Health Image Library: Streptococcus pneumoniae](https://wwwn.cdc.gov/phil/Details.aspx?pid=21340)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Streptococcus pneumoniae appears as gram-positive, lancet-shaped
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diplococci on Gram stain.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-pulmonary-endobronchial-obstruction-5714
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- Source: [Pediatric Bronchoscopy Guidelines](https://archbronconeumol.org/en-pediatric-bronchoscopy-guidelines-articulo-S1579212911000231)
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- Publisher: Archivos de Bronconeumologia
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- Supports: Persistent or recurrent localized pulmonary opacities can reflect an
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unrecognized endobronchial foreign body and warrant airway evaluation.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-obgyn-antiphospholipid-syndrome-5862
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- Source: [The 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria](https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.42624)
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- Publisher: American College of Rheumatology and EULAR
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- Supports: Venous thrombosis and obstetric morbidity are clinical APS domains;
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anticardiolipin antibodies are among the qualifying laboratory antibodies.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-cardiology-vasospastic-angina-3827
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- Source: [2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease](https://www.ahajournals.org/doi/10.1161/CIR.0000000000001168)
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- Publisher: American Heart Association and American College of Cardiology
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- Supports: Nitrate-responsive rest angina, especially between night and early
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morning, supports suspected vasospastic angina; definitive diagnosis also
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requires transient ischemic ECG changes or documented coronary spasm.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-biostatistics-odds-ratio-confidence-interval-417
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- Source: [Analyzing and Interpreting Data](https://www.cdc.gov/field-epi-manual/php/chapters/analyze-interpret-data.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Case-control studies use odds ratios, and the null hypothesis is not
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rejected when a 95% confidence interval includes the null association value
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of 1.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-pediatrics-congenital-cmv-638
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- Source: [Clinical Overview of CMV and Congenital CMV](https://www.cdc.gov/cytomegalovirus/hcp/clinical-overview/index.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Congenital CMV is confirmed by PCR testing of saliva, urine, or blood
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within the first 2-3 weeks of life; urine testing confirms a positive saliva
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screen and distinguishes congenital from postnatal infection.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-epidemiology-dose-response-causality-431
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- Source: [Analyzing and Interpreting Data](https://www.cdc.gov/field-epi-manual/php/chapters/analyze-interpret-data.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Increasing outcome risk with increasing exposure is a dose-response
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relationship, and evidence of this gradient adds weight to causal inference.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-neurology-papilledema-neuroimaging-438
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- Source: [ACR Appropriateness Criteria: Headache](https://acsearch.acr.org/list/TopicNarrativePdf?topicId=140)
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- Publisher: American College of Radiology
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- Supports: Papilledema is a red flag for intracranial hypertension, and
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noncontrast head CT can promptly evaluate secondary causes such as mass,
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edema, or hydrocephalus before lumbar puncture.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-pediatrics-abusive-head-trauma-ct-447
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- Source: [Abusive Head Trauma in Infants and Children: Technical Report](https://publications.aap.org/pediatrics/article/155/3/e2024070457/201049/Abusive-Head-Trauma-in-Infants-and-Children)
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- Publisher: American Academy of Pediatrics
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- Supports: Head CT is the acute imaging modality of choice for cranial and
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intracranial injury in children with neurologic symptoms and concern for
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abuse; children age 2 years or younger also require a skeletal survey.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-ethics-decision-making-capacity-521
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- Source: [Decisions for Adult Patients Who Lack Capacity](https://code-medical-ethics.ama-assn.org/ethics-opinions/decisions-adult-patients-who-lack-capacity)
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- Publisher: American Medical Association
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- Supports: When an adult lacks decision-making capacity, physicians should
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identify and work with the surrogate designated through a durable power of
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attorney for health care; ethics consultation is reserved for absent,
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disputed, or inappropriate surrogate decision-making.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-biostatistics-screening-snout-412
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- Source: [Diagnostic Testing Accuracy: Sensitivity, Specificity, Predictive Values and Likelihood Ratios](https://www.ncbi.nlm.nih.gov/sites/books/NBK557491/)
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- Publisher: National Center for Biotechnology Information
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- Supports: Sensitivity is the true-positive proportion, high sensitivity
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minimizes false negatives, and negative likelihood ratios provide a fuller
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measure of how strongly a negative result lowers disease probability.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-biostatistics-test-characteristics-486
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- Source: [Performance Measures: Assessment of Cancer Screening](https://www.ncbi.nlm.nih.gov/books/NBK550207/)
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- Publisher: National Center for Biotechnology Information
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- Supports: Sensitivity, specificity, PPV, and NPV derive from the diagnostic
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2x2 table, and PPV can remain low for a rare disease despite high sensitivity
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and specificity.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-preventive-care-smoking-cessation-593
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- Source: [Tobacco Smoking Cessation in Adults: Interventions](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions)
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- Publisher: U.S. Preventive Services Task Force
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- Supports: Clinicians should ask adults about tobacco use, advise cessation,
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and provide behavioral interventions and FDA-approved pharmacotherapy to
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nonpregnant adults who smoke.
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- Source: [Colorectal Cancer Screening](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening)
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- Publisher: U.S. Preventive Services Task Force
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- Supports: Average-risk colorectal cancer screening begins at age 45.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-pediatrics-kawasaki-coronary-aneurysm-701
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- Source: [Update on Diagnosis and Management of Kawasaki Disease](https://professional.heart.org/en/science-news/update-on-diagnosis-and-management-of-kawasaki-disease/top-things-to-know)
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- Publisher: American Heart Association
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- Supports: Kawasaki disease can cause coronary artery dilation and aneurysms;
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coronary Z-score assessment and ongoing cardiac imaging guide risk assessment
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and follow-up.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-heartfailure-aldosterone-antagonist-884
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- Source: [2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure](https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063)
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- Publisher: American Heart Association, American College of Cardiology, and
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Heart Failure Society of America
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- Supports: An MRA is recommended to reduce morbidity and mortality in
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symptomatic HFrEF when eGFR is greater than 30 mL/min/1.73 m2 and potassium
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is below 5.0 mEq/L.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-gastroenterology-peptic-ulcer-prognosis-905
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- Source: [ACG Guideline on Treatment of Helicobacter pylori](https://gi.org/journals-publications/ebgi/schoenfeld_sep2024/)
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- Publisher: American College of Gastroenterology
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- Supports: H. pylori infection should be treated and eradication confirmed at
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least 4 weeks after antibiotic therapy, with PPIs held before testing.
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- Source: [The Role of Endoscopy in Peptic Ulcer Disease](https://www.asge.org/docs/default-source/education/practice_guidelines/doc-the-role-of-endoscopy-in-the-management-of-patientswith-peptic-ulcer-disease.pdf)
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- Publisher: American Society for Gastrointestinal Endoscopy
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- Supports: Surveillance endoscopy for a gastric ulcer is individualized based
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on clinical and endoscopic circumstances rather than universally required.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-infectious-disease-antibiotic-stewardship-viral-uri-962
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- Source: [Outpatient Clinical Care for Adults: Antibiotic Prescribing](https://www.cdc.gov/antibiotic-use/hcp/clinical-care/adult-outpatient.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Antibiotics are not recommended for nonspecific viral upper
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respiratory infections, and outpatient evaluation should distinguish
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syndromes requiring antibacterial treatment from self-limited viral illness.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-musculoskeletal-occult-hip-fracture-mri-1007
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- Source: [ACR Appropriateness Criteria: Acute Hip Pain](https://acsearch.acr.org/docs/3082587/narrative)
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- Publisher: American College of Radiology
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- Supports: When traumatic hip fracture is suspected despite negative or
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indeterminate radiographs, MRI without contrast and CT without contrast are
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appropriate next imaging studies.
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- Source: [NICE Hip Fracture Management](https://www.nice.org.uk/guidance/cg124/chapter/recommendations)
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- Publisher: National Institute for Health and Care Excellence
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- Supports: Offer MRI for suspected occult hip fracture after negative x-rays;
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consider CT when MRI is unavailable within 24 hours or contraindicated.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-pediatrics-jia-sports-participation-1134
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- Source: [Exercise and Arthritis](https://rheumatology.org/exercise-and-arthritis)
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- Publisher: American College of Rheumatology
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- Supports: Exercise is recommended for juvenile idiopathic arthritis and can
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be individualized with physical or occupational therapy when modification is
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needed.
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- Source: [2021 ACR JIA Guideline: Nonpharmacologic Therapies](https://pmc.ncbi.nlm.nih.gov/articles/PMC10231687/)
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- Publisher: American College of Rheumatology
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- Supports: Physical and occupational therapy are conditionally recommended in
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JIA but are supportive interventions rather than universal prerequisites for
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activity.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-psychiatry-acute-mania-antipsychotic-1208
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- Source: [VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder](https://www.healthquality.va.gov/guidelines/MH/bd/VA-DoD-CPG-BD-Full-CPGFinal508.pdf)
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- Publisher: U.S. Department of Veterans Affairs and Department of Defense
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- Supports: Quetiapine is an evidence-based monotherapy option for acute mania.
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- Source: [NICE Bipolar Disorder Recommendations](https://www.nice.org.uk/guidance/cg185/chapter/recommendations)
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- Publisher: National Institute for Health and Care Excellence
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- Supports: An antipsychotic such as quetiapine should be offered for mania when
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the patient is not already taking an antipsychotic or mood stabilizer.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-dermatology-acne-comedonal-initial-1209
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- Source: [Acne Clinical Guideline](https://www.aad.org/member/clinical-quality/guidelines/acne)
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- Publisher: American Academy of Dermatology
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- Supports: Current acne guidelines recommend topical retinoids as an effective
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topical therapy and recommend limiting systemic antibiotic use.
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- Source: [Acne: Diagnosis and Treatment](https://www.aad.org/public/diseases/acne/derm-treat/treat)
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- Publisher: American Academy of Dermatology
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- Supports: Topical retinoids, including adapalene, clear pores and treat
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blackheads and whiteheads, supporting their use for isolated comedonal acne.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-infectious-bat-rabies-pep-1847
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- Source: [Preventing Rabies from Bats](https://www.cdc.gov/rabies/prevention/bats.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Bat bites can be difficult to detect; public health or animal
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control should coordinate safe capture and rabies testing of a bat found in
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a home.
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- Source: [Human Rabies Prevention: ACIP Recommendations](https://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e507a1.htm)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: A bat found with an unattended child can constitute a potential
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exposure, but prophylaxis is unnecessary when the captured bat tests
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negative. The 10-day observation rule applies to dogs, cats, and ferrets.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-geriatrics-unintentional-weight-loss-social-isolation-2314
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- Source: [Choosing Wisely](https://www.healthinaging.org/choosing-wisely)
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- Publisher: American Geriatrics Society, Health in Aging Foundation
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- Supports: For anorexia or cachexia in older adults, clinicians should optimize
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social supports, provide appealing food and feeding assistance, and address
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contributing medications rather than routinely prescribing appetite
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stimulants or supplements.
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- Source: [Unintentional Weight Loss in Older Adults](https://www.aafp.org/afp/2021/0700/p34)
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- Publisher: American Academy of Family Physicians
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- Supports: Clinically significant weight loss requires an initial evaluation;
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social isolation can reduce intake, and treatment should address social
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support and the eating environment. Mirtazapine lacks evidence when used
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solely for weight loss and can cause adverse effects in older adults.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-cardiovascular-atrial-fibrillation-stroke-prevention-5172
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- Source: [2023 ACC/AHA/ACCP/HRS Guideline for Atrial Fibrillation](https://www.heart.org/-/media/Files/Professional/Quality-Improvement/Get-With-the-Guidelines/Get-With-The-Guidelines-AFIB/AFib-Month/joglaretal20232023accahaaccphrsguidelineforthediagnosisandmanagementofatrialfibrillation.pdf)
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- Publisher: American College of Cardiology, American Heart Association,
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American College of Chest Physicians, and Heart Rhythm Society
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- Supports: Anticoagulation is recommended for men with atrial fibrillation and
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CHA2DS2-VASc score of at least 2; direct oral anticoagulants are preferred in
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the absence of moderate-to-severe rheumatic mitral stenosis or a mechanical
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valve, and aspirin is not an acceptable substitute for anticoagulation.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-obgyn-abortion-complications-counseling-6815
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- Source: [Abortion Care](https://www.acog.org/womens-health/faqs/induced-abortion)
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- Publisher: American College of Obstetricians and Gynecologists
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- Supports: First-trimester abortion is safe and effective; vaginal bleeding
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and cramping are expected, major complications are rare, and abortion does
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not increase infertility risk.
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- Source: [Abortion Care](https://www.rcog.org.uk/for-the-public/browse-our-patient-information/abortion-care/)
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- Publisher: Royal College of Obstetricians and Gynaecologists
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- Supports: Bleeding and abdominal cramping occur with both medical and
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procedural abortion, and patients should receive anticipatory guidance about
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expected bleeding and warning symptoms.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-pediatrics-sports-clearance-innocent-murmur-1427
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- Source: [Heart Murmurs in Children: Evaluation and Management](https://www.aafp.org/afp/2022/0300/p250)
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- Publisher: American Academy of Family Physicians
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- Supports: In a child older than 2 years, disappearance of a murmur with
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standing strongly supports an innocent murmur; sports clearance is
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appropriate when history and examination are otherwise benign.
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- Source: [The Preparticipation Sports Evaluation](https://www.aafp.org/afp/2015/0901/p371)
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- Publisher: American Academy of Family Physicians
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- Supports: Athletes with well-controlled asthma can participate safely and
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should have a rescue inhaler available; routine pulmonary function testing is
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not required solely for clearance in an asymptomatic athlete with established
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controlled asthma.
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- Source: [Heart Murmurs](https://www.heart.org/en/health-topics/heart-murmurs)
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- Publisher: American Heart Association
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- Supports: Children with innocent murmurs do not require activity limitation.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-immunization-mmr-transient-arthralgia-615
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- Source: [MMR Vaccine Safety](https://www.cdc.gov/vaccine-safety/vaccines/mmr.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Joint pain or stiffness occurs in up to one-quarter of susceptible
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postpubertal females, generally begins 1 to 3 weeks after MMR vaccination,
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is usually mild, lasts about 2 days, and rarely recurs.
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- Source: [Pink Book, Chapter 20: Rubella](https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-20-rubella.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Arthralgia after MMR vaccination is associated with the rubella
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component and occurs much more often in adult women than in children or men.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-integumentary-contaminated-laceration-delayed-closure-2841
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- Source: [Clinical Guidance for Wound Management to Prevent Tetanus](https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: A soil-contaminated wound is a dirty wound; a patient with unknown
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tetanus vaccination history should receive a tetanus-containing vaccine and
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tetanus immune globulin in addition to wound cleaning and debridement.
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- Source: [Skin Lacerations](https://www.msdmanuals.com/professional/injuries-poisoning/lacerations-and-abrasions/skin-lacerations)
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- Publisher: MSD Manual Professional Edition
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- Supports: Delayed primary closure is appropriate for significantly
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contaminated wounds, particularly those containing organic debris; initial
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care includes thorough exploration, debridement, and loose moist-gauze
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packing followed by reassessment for closure.
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- Accessed: 2026-07-12
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- Reviewer: Codex
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## step3-tetanus-prophylaxis-001
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- Source: [Clinical Guidance for Wound Management to Prevent Tetanus](https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html)
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- Publisher: Centers for Disease Control and Prevention
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- Supports: Puncture wounds and wounds containing soil are dirty or major
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wounds. Patients with unknown vaccination history require a tetanus
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toxoid-containing vaccine, and those with dirty or major wounds also require
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tetanus immune globulin for immediate passive protection.
|
|
- Source: [Pink Book, Chapter 21: Tetanus](https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-21-tetanus.html)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Patients with non-clean wounds and unknown or fewer than three
|
|
prior tetanus vaccine doses should receive both vaccine and tetanus immune
|
|
globulin; Tdap is preferred when prior Tdap history is unknown.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-derm-alopecia-areata-001
|
|
|
|
- Source: [Alopecia Areata: Diagnosis and Treatment](https://www.aad.org/public/diseases/hair-loss/types/alopecia/treatment)
|
|
- Publisher: American Academy of Dermatology
|
|
- Supports: Intralesional corticosteroid injections are considered the most
|
|
effective treatment for adults with a few patches of alopecia areata; hair
|
|
regrowth is often seen within approximately 3 months when treatment works.
|
|
- Source: [Alopecia Areata: Signs and Symptoms](https://www.aad.org/public/diseases/hair-loss/types/alopecia/symptoms)
|
|
- Publisher: American Academy of Dermatology
|
|
- Supports: Alopecia areata commonly presents with sudden round or oval smooth
|
|
patches of nonscarring hair loss without scalp irritation.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-cardiology-pci-restenosis-001
|
|
|
|
- Source: [SCAI Expert Consensus Statement on Management of In-Stent Restenosis and Stent Thrombosis](https://www.scai.org/publications/clinical-documents/scai-expert-consensus-statement-management-stent-restenosis-and)
|
|
- Publisher: Society for Cardiovascular Angiography and Interventions
|
|
- Supports: In-stent restenosis and stent thrombosis are distinct post-PCI
|
|
complications with different mechanisms and management considerations.
|
|
- Source: [Antiplatelet Strategies in Percutaneous Coronary Interventions](https://www.acc.org/-/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Membership/Coronary-Interventions-Handbook/Chapter-4_Antiplatelet-Strategies.pdf)
|
|
- Publisher: American College of Cardiology
|
|
- Supports: Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is a
|
|
cornerstone of peri-procedural and post-stent therapy to reduce stent
|
|
thrombosis.
|
|
- Source: [2021 ACC/AHA/SCAI Revascularization Guideline: Key Perspectives](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/12/08/21/19/2021-guideline-for-revascularization-gl-revasc)
|
|
- Publisher: American College of Cardiology
|
|
- Supports: Antiplatelet therapy after PCI is selected and continued according
|
|
to ischemic and bleeding risk; drug-eluting stents are standard contemporary
|
|
PCI devices.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-gi-barrett-gerd-001
|
|
|
|
- Source: [Barrett's Esophagus](https://gi.org/topics/barretts-esophagus/)
|
|
- Publisher: American College of Gastroenterology
|
|
- Supports: Most patients with Barrett esophagus receive proton pump inhibitor
|
|
therapy; antireflux surgery is used for GERD indications rather than as a
|
|
cancer-prevention treatment, and nondysplastic Barrett esophagus is managed
|
|
with surveillance rather than eradication therapy.
|
|
- Source: [Acid Reflux/GERD](https://gi.org/topics/acid-reflux/)
|
|
- Publisher: American College of Gastroenterology
|
|
- Supports: Proton pump inhibitors and lifestyle measures are effective GERD
|
|
therapy; objective reflux testing is particularly useful when symptoms are
|
|
not controlled or antireflux surgery is being considered.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-gi-cdiff-complication-001
|
|
|
|
- Source: [C. diff: Facts for Clinicians](https://www.cdc.gov/c-diff/hcp/clinical-overview/)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Recognized severe complications of C. difficile infection include
|
|
toxic megacolon, colonic perforation, sepsis, and death.
|
|
- Source: [SHEA/IDSA Clinical Practice Guideline for C. difficile Infection](https://www.idsociety.org/practice-guideline/clostridium-difficile/)
|
|
- Publisher: Infectious Diseases Society of America and Society for Healthcare
|
|
Epidemiology of America
|
|
- Supports: Fulminant C. difficile infection may be characterized by
|
|
hypotension or shock, ileus, or megacolon; megacolon and perforation may
|
|
require urgent surgical management.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-rheumatology-cppd-acute-treatment-734
|
|
|
|
- Source: [Calcium Pyrophosphate Deposition](https://rheumatology.org/patients/calcium-pyrophosphate-deposition-cppd)
|
|
- Publisher: American College of Rheumatology
|
|
- Supports: Acute CPP crystal arthritis may be treated with joint aspiration
|
|
and glucocorticoid injection or systemic anti-inflammatory therapy including
|
|
NSAIDs, oral glucocorticoids, or colchicine.
|
|
- Source: [Calcium Pyrophosphate Deposition Disease](https://www.msdmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/crystal-induced-arthritides/calcium-pyrophosphate-deposition-disease)
|
|
- Publisher: MSD Manual Professional Edition
|
|
- Supports: Colchicine is an accepted treatment for acute CPP arthritis flares;
|
|
NSAIDs and glucocorticoids are alternatives selected according to the number
|
|
of affected joints and patient-specific contraindications.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-infectious-tuberculosis-screening-conversion-237
|
|
|
|
- Source: [Clinical Testing Guidance for Tuberculosis: Tuberculin Skin Test](https://www.cdc.gov/tb/hcp/testing-diagnosis/tuberculin-skin-test.html)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: A positive tuberculin skin test requires evaluation for TB disease;
|
|
the result must be interpreted according to exposure and progression risk.
|
|
- Source: [ATS/CDC/IDSA Diagnosis of Tuberculosis Guideline](https://www.idsociety.org/practice-guideline/diagnosis-of-tb-in-adults-and-children/)
|
|
- Publisher: American Thoracic Society, Centers for Disease Control and
|
|
Prevention, and Infectious Diseases Society of America
|
|
- Supports: Active TB is excluded by symptom assessment and chest radiography;
|
|
respiratory sampling follows when symptoms or radiographic abnormalities
|
|
suggest pulmonary disease. Confirmatory testing is mainly advised for an
|
|
unexpected positive result in a person unlikely to be infected.
|
|
- Source: [CDC Contact Investigation Recommendations](https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm)
|
|
- Publisher: Centers for Disease Control and Prevention and National
|
|
Tuberculosis Controllers Association
|
|
- Supports: TST conversion is conventionally defined by an increase of at least
|
|
10 mm within 2 years.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-gastro-sbp-saag-241
|
|
|
|
- Source: [Recognition and Management of Spontaneous Bacterial Peritonitis](https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/spontaneous-bacterial-peritonitis-recognition-management/core-concept/all/)
|
|
- Publisher: University of Washington Hepatitis C Online
|
|
- Supports: Ascitic fluid PMN count of at least 250 cells/mm3 warrants prompt
|
|
empiric antibiotics; community-acquired SBP is treated with intravenous
|
|
cefotaxime or a similar third-generation cephalosporin, whereas nosocomial
|
|
infection may require broader therapy.
|
|
- Source: [AASLD: Why Timing Matters, Paracentesis on Admission](https://www.aasld.org/liver-fellow-network/core-series/why-series/why-timing-matters-paracentesis-admission-cirrhosis)
|
|
- Publisher: American Association for the Study of Liver Diseases
|
|
- Supports: In a patient with cirrhosis and ascites, an ascitic PMN count of at
|
|
least 250 cells/uL carries a high likelihood of SBP and should prompt
|
|
antibiotic treatment without waiting for culture results.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-cardiovascular-thiazide-followup-251
|
|
|
|
- Source: [2025 High Blood Pressure Guideline: Top Things to Know](https://professional.heart.org/en/science-news/2025-high-blood-pressure-guideline/top-things-to-know)
|
|
- Publisher: American Heart Association and American College of Cardiology
|
|
- Supports: Stage 2 hypertension is preferably treated with two first-line
|
|
agents; home blood pressure monitoring and frequent follow-up are important
|
|
while therapy is being adjusted, and a potassium-rich DASH-style diet is
|
|
recommended when clinically appropriate.
|
|
- Source: [Chlorthalidone Prescribing Information](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=36ef8d83-45f2-4873-b7cb-1be096d14d18)
|
|
- Publisher: U.S. National Library of Medicine DailyMed
|
|
- Supports: Chlorthalidone can cause dose-related potassium reduction;
|
|
electrolytes should be checked periodically, dose titration should follow a
|
|
suitable therapeutic trial, and elderly patients should generally begin at
|
|
the low end of the dose range.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-psych-acute-psychosis-261
|
|
|
|
- Source: [Adult Psychiatric Emergencies](https://www.acep.org/siteassets/new-pdfs/policy-statements/adult-psychiatric-emergencies.pdf)
|
|
- Publisher: American College of Emergency Physicians
|
|
- Supports: Psychosis and homicidal or violent behavior are psychiatric
|
|
emergencies requiring risk stratification, acute treatment, and a safe
|
|
disposition rather than routine outpatient follow-up.
|
|
- Source: [Crisis Services: Meeting Needs, Saving Lives](https://988crisissystemshelp.samhsa.gov/sites/default/files/2024-01/crisis-services-meeting-needs-saving-lives-compendium.pdf)
|
|
- Publisher: Substance Abuse and Mental Health Services Administration
|
|
- Supports: Acute psychiatric symptoms may require inpatient stabilization;
|
|
risk of injury to others is a common civil-commitment criterion, although
|
|
specific involuntary-hold procedures vary by jurisdiction.
|
|
- Source: [What Is Schizophrenia?](https://www.samhsa.gov/mental-health/what-is-mental-health/conditions/schizophrenia)
|
|
- Publisher: Substance Abuse and Mental Health Services Administration
|
|
- Supports: Hospitalization may be needed during a severe schizophrenia
|
|
episode to ensure safety and stabilization.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-pulmonary-copd-niv-271
|
|
|
|
- Source: [GOLD 2026 Report](https://goldcopd.org/wp-content/uploads/2026/01/GOLD-REPORT-2026-v1.3-8Dec2025_WMV2.pdf)
|
|
- Publisher: Global Initiative for Chronic Obstructive Lung Disease
|
|
- Supports: NIV is the initial ventilatory mode for hospitalized COPD
|
|
exacerbations with acute respiratory failure and is indicated with
|
|
respiratory acidosis, including PaCO2 at least 45 mm Hg and pH at or below
|
|
7.35; it reduces intubation, complications, and mortality.
|
|
- Source: [ERS/ATS Guideline on NIV for Acute Respiratory Failure](https://publications.ersnet.org/content/erj/50/2/1602426.full)
|
|
- Publisher: European Respiratory Society and American Thoracic Society
|
|
- Supports: Bilevel NIV is strongly recommended for acute or acute-on-chronic
|
|
respiratory acidosis due to COPD exacerbation, particularly at pH 7.25 to
|
|
7.35 when the patient is not immediately deteriorating and can be closely
|
|
monitored with rapid access to intubation.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-supportive-care-acupuncture-cinv-2801
|
|
|
|
- Source: [Acupuncture PDQ, Health Professional Version](https://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq)
|
|
- Publisher: National Cancer Institute
|
|
- Supports: Among cancer-related symptoms studied, acupuncture has its most
|
|
convincing evidence for chemotherapy-induced nausea and vomiting; it may be
|
|
used as an adjunct to standard antiemetic therapy, although study quality and
|
|
effects on specific nausea and vomiting outcomes vary.
|
|
- Source: [Nausea and Vomiting Related to Cancer Treatment PDQ](https://www.cancer.gov/about-cancer/treatment/side-effects/nausea/nausea-hp-pdq)
|
|
- Publisher: National Cancer Institute
|
|
- Supports: Persistent CINV can cause dehydration and nutritional depletion;
|
|
management requires optimized pharmacologic antiemetics, dietary support,
|
|
and selected nonpharmacologic adjuncts such as acupuncture or acupressure.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-pulmonary-silicosis-progressive-fibrosis-2901
|
|
|
|
- Source: [Engineered Stone and Silicosis](https://www.cdc.gov/niosh/bulletin/2026/engineered-stone-cos.html)
|
|
- Publisher: National Institute for Occupational Safety and Health
|
|
- Supports: Engineered stone typically contains very high crystalline silica
|
|
content, and respirable exposure during fabrication can cause irreversible
|
|
occupational silicosis.
|
|
- Source: [Outbreak of Silicosis Among Engineered Stone Countertop Workers](https://www.cdc.gov/niosh/bulletin/2019/silicosis-countertop.html)
|
|
- Publisher: National Institute for Occupational Safety and Health
|
|
- Supports: Silicosis is progressive, debilitating, incurable, and sometimes
|
|
fatal; high-level engineered-stone exposure can produce severe disease.
|
|
- Source: [Severe Silicosis in Engineered Stone Fabrication Workers](https://www.cdc.gov/mmwr/volumes/68/wr/mm6838a1.htm)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Progressive massive fibrosis is the most advanced form of
|
|
silicosis and can cause continued lung-function decline requiring lung
|
|
transplantation evaluation; silicosis also increases tuberculosis risk.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-neurology-tia-secondary-prevention-3201
|
|
|
|
- Source: [2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke](https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke/top-things-to-know)
|
|
- Publisher: American Heart Association/American Stroke Association
|
|
- Supports: Eligible patients with disabling acute ischemic stroke deficits
|
|
should receive rapid intravenous thrombolysis within 4.5 hours regardless of
|
|
NIHSS score, whereas dual antiplatelet therapy is preferred for selected
|
|
nondisabling events.
|
|
- Source: [2021 Guideline for Prevention of Stroke in Patients With Stroke and TIA](https://professional.heart.org/en/science-news/2021-guideline-for-the-prevention-of-stroke-in-patients-with-stroke-and-transient-ischemic-attack/top-things-to-know)
|
|
- Publisher: American Heart Association/American Stroke Association
|
|
- Supports: Short-term dual antiplatelet therapy is recommended only for
|
|
selected patients, including early-arriving minor ischemic stroke and
|
|
high-risk transient ischemic attack; occult atrial-fibrillation monitoring
|
|
is also appropriate when no other cause is identified.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-neuro-acute-dystonia-337
|
|
|
|
- Source: [Reglan injection prescribing information](https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/017862s64lbl.pdf)
|
|
- Publisher: U.S. Food and Drug Administration
|
|
- Supports: Metoclopramide can cause acute dystonic reactions within the first
|
|
24-48 hours, including torticollis, trismus, and oculogyric crisis;
|
|
diphenhydramine or benztropine can treat the reaction, and metoclopramide
|
|
should be discontinued when extrapyramidal symptoms develop.
|
|
- Source: [Treatment of acute adverse effects of antipsychotics](https://www.merckmanuals.com/professional/psychiatric-disorders/schizophrenia-and-related-disorders/antipsychotic-medications)
|
|
- Publisher: Merck Manual Professional Edition
|
|
- Supports: Acute dystonic reactions such as oculogyric crisis and torticollis
|
|
are treated with intravenous or intramuscular diphenhydramine or benztropine.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-endocrine-diabetic-nephropathy-401
|
|
|
|
- Source: [Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes - 2026](https://diabetesjournals.org/care/article/49/Supplement_1/S246/163914/11-Chronic-Kidney-Disease-and-Risk-Management)
|
|
- Publisher: American Diabetes Association
|
|
- Supports: In nonpregnant people with diabetes and hypertension, an ACE
|
|
inhibitor or ARB is recommended when UACR is 30-299 mg/g and is strongly
|
|
recommended with UACR at least 300 mg/g and/or eGFR below 60. Evidence does
|
|
not establish kidney-outcome benefit for moderately increased albuminuria
|
|
without hypertension, and abnormal UACR should be confirmed because of
|
|
biological variability.
|
|
- Source: [ADA-KDIGO consensus report on diabetes management in CKD](https://diabetesjournals.org/care/article/45/12/3075/147614/Diabetes-Management-in-Chronic-Kidney-Disease-A)
|
|
- Publisher: American Diabetes Association and Kidney Disease: Improving Global Outcomes
|
|
- Supports: ACE inhibitor or ARB therapy is recommended and titrated to the
|
|
highest tolerated dose in patients with diabetes, hypertension, and
|
|
albuminuria.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-genitourinary-chronic-bacterial-prostatitis-302
|
|
|
|
- Source: [EAU Guidelines on Urological Infections: Bacterial Prostatitis](https://uroweb.org/guidelines/urological-infections/chapter/the-guideline?s=04)
|
|
- Publisher: European Association of Urology
|
|
- Supports: Chronic bacterial prostatitis should receive culture-guided
|
|
antimicrobial treatment; fluoroquinolones are recommended first-line for
|
|
susceptible typical gram-negative pathogens and are generally given for
|
|
4-6 weeks because of their prostatic penetration.
|
|
- Source: [Fluoroquinolone safety reminder](https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-reminder-of-the-risk-of-disabling-and-potentially-long-lasting-or-irreversible-side-effects)
|
|
- Publisher: UK Medicines and Healthcare products Regulatory Agency
|
|
- Supports: Fluoroquinolones can cause disabling, prolonged, or irreversible
|
|
adverse effects and require patient counseling and prompt discontinuation if
|
|
serious tendon, muscle, joint, peripheral nerve, or central nervous system
|
|
symptoms develop.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-em-criticalcare-hypothermia-403
|
|
|
|
- Source: [AHA Special Circumstances of Resuscitation](https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-and-pediatric-special-circumstances-of-resuscitation)
|
|
- Publisher: American Heart Association
|
|
- Supports: Full resuscitation and rewarming should continue in life-threatening
|
|
environmental hypothermia without an obviously lethal injury. Prognosis for
|
|
extracorporeal rewarming should use the validated HOPE score, which includes
|
|
age, sex, asphyxia, CPR duration, serum potassium, and core temperature;
|
|
isolated clinical or laboratory findings should not determine futility.
|
|
- Source: [2025 Special Circumstances Guidelines](https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/special-circumstances-guidelines)
|
|
- Publisher: Resuscitation Council UK
|
|
- Supports: In-hospital prognostication for successful rewarming after
|
|
hypothermic cardiac arrest should be based on the HOPE score.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-obgyn-hellp-urgent-delivery-404
|
|
|
|
- Source: [Preeclampsia and High Blood Pressure During Pregnancy](https://www.acog.org/womens-health/faqs/preeclampsia-and-high-blood-pressure-during-pregnancy)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: HELLP syndrome is a medical emergency. Preeclampsia with severe
|
|
features at or beyond 34 weeks should be managed in the hospital with
|
|
maternal stabilization, seizure prophylaxis and blood-pressure treatment as
|
|
indicated, followed by delivery once stable.
|
|
- Source: [ACOG overview: 7 Things to Know About Preeclampsia](https://www.acog.org/womens-health/experts-and-stories/the-latest/7-things-to-know-about-preeclampsia)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: HELLP requires immediate delivery; severe preeclampsia at or after
|
|
34 weeks generally warrants delivery, with antihypertensive medication and
|
|
magnesium sulfate used during stabilization.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-endocrine-primary-aldosteronism-medical-therapy-506
|
|
|
|
- Source: [Primary Aldosteronism: Endocrine Society Clinical Practice Guideline](https://www.endocrine.org/clinical-practice-guidelines/primary-aldosteronism-2)
|
|
- Publisher: Endocrine Society
|
|
- Supports: Primary aldosteronism should receive aldosterone-specific therapy.
|
|
Lifelong mineralocorticoid receptor antagonist treatment is appropriate for
|
|
bilateral disease, unknown lateralization, patients who decline surgery, or
|
|
those who are not surgical candidates; spironolactone is suggested because
|
|
of cost and availability, with potassium, renal function, renin, and blood
|
|
pressure monitored during titration.
|
|
- Source: [Primary Aldosteronism guideline full text](https://academic.oup.com/jcem/article/110/9/2453/8196671)
|
|
- Publisher: Journal of Clinical Endocrinology & Metabolism
|
|
- Supports: CT imaging cannot reliably determine functional lateralization.
|
|
Patients who desire and are candidates for adrenalectomy generally require
|
|
CT plus adrenal venous sampling before choosing surgical therapy.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-infectious-mrsa-pneumonia-linezolid-707
|
|
|
|
- Source: [ATS/IDSA Community-Acquired Pneumonia Guideline Executive Summary](https://www.idsociety.org/globalassets/idsa/practice-guidelines/community-acquired-pneumonia-in-adults/executive_summary.pdf)
|
|
- Publisher: American Thoracic Society and Infectious Diseases Society of America
|
|
- Supports: Recommended MRSA-active treatment options for hospitalized adults
|
|
with community-acquired pneumonia include vancomycin or linezolid.
|
|
- Source: [ATS/IDSA HAP/VAP Guideline](https://www.idsociety.org/practice-guideline/hap_vap/)
|
|
- Publisher: American Thoracic Society and Infectious Diseases Society of America
|
|
- Supports: Confirmed MRSA pneumonia should be treated with vancomycin or
|
|
linezolid; patient-specific factors such as renal function, blood counts,
|
|
serotonergic medications, and cost can guide selection.
|
|
- Source: [Daptomycin prescribing information](https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/217630s000lbl.pdf)
|
|
- Publisher: U.S. Food and Drug Administration
|
|
- Supports: Daptomycin is not indicated for treatment of pneumonia.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-endocrine-new-diabetes-lipid-screen-842
|
|
|
|
- Source: [Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2026](https://diabetesjournals.org/care/article/49/Supplement_1/S216/163933/10-Cardiovascular-Disease-and-Risk-Management)
|
|
- Publisher: American Diabetes Association
|
|
- Supports: Adults with diabetes aged 40-75 years without ASCVD should receive
|
|
at least moderate-intensity statin therapy. A lipid profile establishes the
|
|
baseline needed to assess LDL reduction, identify severe dyslipidemia, and
|
|
monitor response and adherence after therapy begins.
|
|
- Source: [Comprehensive Medical Evaluation: Standards of Care in Diabetes - 2026](https://diabetesjournals.org/care/article/49/Supplement_1/S61/163931/4-Comprehensive-Medical-Evaluation-and-Assessment)
|
|
- Publisher: American Diabetes Association
|
|
- Supports: Adults with type 2 diabetes should also be assessed for metabolic
|
|
liver fibrosis risk with FIB-4, which uses age, AST, ALT, and platelet count;
|
|
therefore hepatic enzymes and CBC components should not be presented as
|
|
categorically unnecessary distractors in an initial diabetes evaluation.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-neuro-missed-antiseizure-dose-316
|
|
|
|
- Source: [Levetiracetam Medication Guide](https://www.dailymed.nlm.nih.gov/dailymed/medguide.cfm?setid=0f60b9fb-5305-4488-99b7-a01a693994b4)
|
|
- Publisher: U.S. National Library of Medicine DailyMed
|
|
- Supports: A missed levetiracetam dose should be taken when remembered unless
|
|
it is almost time for the next dose; in that case, the missed dose should be
|
|
skipped and the next dose taken at the regular time without doubling.
|
|
- Source: [How and when to take levetiracetam](https://www.nhs.uk/medicines/levetiracetam/how-and-when-to-take-levetiracetam/)
|
|
- Publisher: National Health Service
|
|
- Supports: For twice-daily levetiracetam, if fewer than 8 hours remain before
|
|
the next dose, skip the missed dose and take the next dose normally; never
|
|
take an extra dose to compensate.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-ethics-shared-decision-oncology-481
|
|
|
|
- Source: [Surgery to Reduce the Risk of Breast Cancer](https://www.cancer.gov/types/breast/causes-risk-factors/prevention/preventive-breast-surgery)
|
|
- Publisher: National Cancer Institute
|
|
- Supports: Contralateral risk-reducing mastectomy lowers contralateral cancer
|
|
incidence but is generally discouraged for average-risk patients because
|
|
contralateral risk is low, complications may increase, and available evidence
|
|
does not show reduced mortality; benefits and harms should be individualized
|
|
and discussed.
|
|
- Source: [Mastectomy: Single vs. Double Mastectomy](https://www.cancer.gov/types/breast/treatment/surgery/mastectomy)
|
|
- Publisher: National Cancer Institute
|
|
- Supports: Patients without a high-risk mutation or strong family history do
|
|
not generally live longer after double rather than single mastectomy, but
|
|
concerns about recurrence, surveillance, symmetry, body image, reconstruction,
|
|
risks, and patient preferences should be discussed in shared decision-making.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-neuro-ischemic-stroke-supportive-bp-615
|
|
|
|
- Source: [2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke](https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke)
|
|
- Publisher: American Heart Association/American Stroke Association
|
|
- Supports: Current acute ischemic stroke guidance emphasizes rapid assessment for
|
|
intravenous thrombolysis and endovascular thrombectomy, including expanded
|
|
thrombectomy eligibility, and warns against intensive blood pressure lowering
|
|
around reperfusion treatment.
|
|
- Source: [2025 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults](https://www.ahajournals.org/doi/10.1161/HYP.0000000000000249)
|
|
- Publisher: American Heart Association/American College of Cardiology
|
|
- Supports: In acute ischemic stroke, blood pressure treatment depends on
|
|
reperfusion status, a pressure above 220/120 mm Hg, or another comorbid
|
|
indication; rapid reduction can be detrimental because ischemic tissue depends
|
|
on systemic perfusion pressure.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-urogynecology-stress-incontinence-pessary-612
|
|
|
|
- Source: [Urinary Incontinence](https://www.acog.org/womens-health/faqs/urinary-incontinence)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: Stress urinary incontinence causes leakage with coughing, laughing,
|
|
walking, running, or exercise; a fitted pessary can support the vaginal walls,
|
|
bladder, and urethra and provide symptom relief without surgery.
|
|
- Source: [Pelvic Support Problems](https://www.acog.org/womens-health/faqs/pelvic-support-problems)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: Anterior vaginal wall prolapse results from weakened pelvic support;
|
|
pessaries can be used for short- or long-term support and many patients obtain
|
|
immediate relief, while pelvic floor exercises may also improve incontinence.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-cardiology-preop-ecg-incidental-552
|
|
|
|
- Source: [2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery](https://professional.heart.org/en/-/media/PHD-Files-2/Science-News/2/2024/2024-Guideline-for-Perioperative-Cardiovascular-Management-slide-set.pdf)
|
|
- Publisher: American Heart Association/American College of Cardiology
|
|
- Supports: Routine resting ECG is not recommended for asymptomatic patients
|
|
undergoing low-risk surgery; further evaluation is reasonable for new ECG
|
|
abnormalities, not an unchanged chronic finding.
|
|
- Source: [2024 AHA/ACC Perioperative Cardiovascular Management Guideline: Key Points](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/09/23/04/15/2024-aha-acc-perioperative-guideline-gl)
|
|
- Publisher: American College of Cardiology
|
|
- Supports: Patients with good functional capacity, low predicted perioperative
|
|
risk, or a planned low-risk procedure should not undergo routine preoperative
|
|
stress testing.
|
|
- Media: Original ECG schematic created for this question; no third-party image
|
|
was uploaded.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-psychiatry-late-life-depression-mirtazapine-714
|
|
|
|
- Source: [VA/DoD Clinical Practice Guideline: Management of Major Depressive Disorder](https://www.healthquality.va.gov/guidelines/MH/mdd/)
|
|
- Publisher: U.S. Department of Veterans Affairs and Department of Defense
|
|
- Supports: Major depressive disorder should be treated with evidence-based
|
|
pharmacotherapy and/or psychotherapy selected according to clinical features,
|
|
patient preferences, comorbidities, and adverse-effect profiles.
|
|
- Source: [Mirtazapine Prescribing Information](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=98ad1917-a094-44f5-a28f-a64a8cfcd887)
|
|
- Publisher: U.S. National Library of Medicine DailyMed
|
|
- Supports: Mirtazapine is indicated for major depressive disorder; common
|
|
effects include somnolence, increased appetite, weight gain, and dizziness,
|
|
which informs individualized use and monitoring in an older patient with
|
|
insomnia and clinically significant weight loss.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-bone-health-osteoporosis-bisphosphonate-815
|
|
|
|
- Source: [Pharmacological Management of Osteoporosis in Postmenopausal Women](https://www.endocrine.org/clinical-practice-guidelines/osteoporosis-in-postmenopausal-women)
|
|
- Publisher: Endocrine Society
|
|
- Supports: Bisphosphonates are recommended as initial therapy for postmenopausal
|
|
women at high fracture risk; raloxifene is limited to women at low DVT risk,
|
|
menopausal hormone therapy is limited to selected younger women at low DVT
|
|
risk, and calcitonin is reserved for patients unable to use preferred agents.
|
|
- Source: [Raloxifene Prescribing Information](https://www.accessdata.fda.gov/drugsatfda_docs/review/2018/090842Orig1s000.pdf)
|
|
- Publisher: U.S. Food and Drug Administration
|
|
- Supports: Raloxifene is contraindicated in women with an active or past history
|
|
of venous thromboembolism, including deep venous thrombosis and pulmonary
|
|
embolism.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-endocrine-dka-dextrose-potassium-916
|
|
|
|
- Source: [Hyperglycemic Crises in Adults With Diabetes: A Consensus Report](https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A)
|
|
- Publisher: American Diabetes Association and European Association for the Study of Diabetes
|
|
- Supports: When glucose falls below 250 mg/dL during DKA treatment, add 5%-10%
|
|
dextrose and reduce but continue intravenous insulin until ketonemia resolves;
|
|
add potassium when serum potassium falls below 5.0 mmol/L to maintain 4-5
|
|
mmol/L, and reserve bicarbonate for severe acidosis with pH below 7.0.
|
|
- Source: [Hyperglycemic Crises in Adults With Diabetes: Full Consensus Report](https://pmc.ncbi.nlm.nih.gov/articles/PMC11272983/)
|
|
- Publisher: Diabetes Care via PubMed Central
|
|
- Supports: DKA resolution requires beta-hydroxybutyrate below 0.6 mmol/L plus
|
|
venous pH at least 7.3 or bicarbonate at least 18 mmol/L; glucose normalization
|
|
alone is not sufficient to stop insulin.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-substance-use-alcohol-blackout-counseling-917
|
|
|
|
- Source: [Interrupted Memories: Alcohol-Induced Blackouts](https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/interrupted-memories-alcohol-induced-blackouts)
|
|
- Publisher: National Institute on Alcohol Abuse and Alcoholism
|
|
- Supports: During an alcohol-induced blackout a person remains awake but cannot
|
|
consolidate new memories; even one blackout is concerning, predicts increased
|
|
risk of alcohol-related harms, and should prompt discussion and assessment of
|
|
drinking behavior.
|
|
- Source: [Screening, Brief Intervention, and Referral to Treatment](https://www.samhsa.gov/substance-use/treatment/sbirt)
|
|
- Publisher: Substance Abuse and Mental Health Services Administration
|
|
- Supports: Emergency departments are appropriate settings for validated
|
|
substance-use screening, brief intervention for at-risk use, and referral for
|
|
additional assessment or treatment when indicated.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-gastroenterology-splenic-infarction-post-sclerotherapy-918
|
|
|
|
- Source: [Splenic Abscess: A Possible Complication of Endoscopic Variceal Sclerotherapy](https://pubmed.ncbi.nlm.nih.gov/8340143/)
|
|
- Publisher: PubMed-indexed case report
|
|
- Supports: Splenic abscess is a reported rare complication of endoscopic
|
|
variceal sclerotherapy, potentially related to bacteremia or retrograde portal
|
|
venous thrombosis after the procedure.
|
|
- Source: [AAST Acute Care Surgery Curriculum: Splenic Abscess](https://www.aast.org/Assets/732276a6-7a75-44d8-99c8-a364158e7833/638578976049130000/e15-splenic-abscess-pdf)
|
|
- Publisher: American Association for the Surgery of Trauma
|
|
- Supports: CT establishes the diagnosis; initial treatment includes hospital
|
|
admission and broad-spectrum antibiotics, with definitive source control by
|
|
percutaneous drainage or splenectomy selected according to anatomy and clinical
|
|
status.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-gynecology-pessary-vaginitis-919
|
|
|
|
- Source: [Vaginal Pessary Use and Management for Pelvic Organ Prolapse](https://www.augs.org/clinical-patient-resources/clinical-guidance-documents/)
|
|
- Publisher: American Urogynecologic Society and Society of Urologic Nurses and Associates
|
|
- Supports: AUGS identifies its joint clinical consensus statement as current
|
|
guidance for pessary use, surveillance, and management of pessary-related
|
|
complications.
|
|
- Source: [Updates in Pessary Care for Pelvic Organ Prolapse: A Narrative Review](https://pmc.ncbi.nlm.nih.gov/articles/PMC12028327/)
|
|
- Publisher: Journal of Clinical Medicine via PubMed Central
|
|
- Supports: Pessary-associated discharge is common and does not necessarily
|
|
indicate infection; pessary-related epithelial changes are classified by
|
|
direct examination, and management may include cleaning, temporary removal,
|
|
vaginal assessment, and treatment directed by the observed complication.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-pulmonary-copd-exacerbation-bronchodilator-920
|
|
|
|
- Source: [Global Initiative for Chronic Obstructive Lung Disease 2026 Report](https://goldcopd.org/wp-content/uploads/2026/01/GOLD-REPORT-2026-v1.3-8Dec2025_WMV2.pdf)
|
|
- Publisher: Global Initiative for Chronic Obstructive Lung Disease
|
|
- Supports: Short-acting inhaled beta2-agonists, with or without short-acting
|
|
anticholinergics, are the initial bronchodilators for an acute COPD
|
|
exacerbation. Systemic corticosteroids improve recovery, and antibiotics are
|
|
indicated when increased sputum purulence accompanies other cardinal symptoms
|
|
or mechanical ventilation is required.
|
|
- Source: [Chronic Obstructive Pulmonary Disease in Over 16s: Diagnosis and Management](https://www.nice.org.uk/guidance/ng115/chapter/recommendations)
|
|
- Publisher: National Institute for Health and Care Excellence
|
|
- Supports: Acute exacerbation management includes increased short-acting
|
|
bronchodilator therapy, controlled oxygen when needed, systemic corticosteroids
|
|
for significant breathlessness, and antibiotics when sputum changes suggest a
|
|
bacterial trigger.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-obgyn-tuboovarian-abscess-641
|
|
|
|
- Source: [Pelvic Inflammatory Disease: STI Treatment Guidelines](https://www.cdc.gov/std/treatment-guidelines/pid.htm)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Tubo-ovarian abscess is an indication for hospitalization and more
|
|
than 24 hours of inpatient observation. Recommended parenteral therapy includes
|
|
ceftriaxone, doxycycline, and metronidazole, with continued anaerobic coverage
|
|
when an abscess is present.
|
|
- Source: [Pelvic Inflammatory Disease](https://www.acog.org/womens-health/faqs/pelvic-inflammatory-disease)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: PID can produce a tubo-ovarian abscess; antibiotics are the usual
|
|
initial treatment, while selected abscesses may require a procedure or surgery.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-musculoskeletal-scoliosis-screen-422
|
|
|
|
- Source: [Adolescent Idiopathic Scoliosis: Screening](https://www.uspreventiveservicestaskforce.org/uspstf/index.php/recommendation/adolescent-idiopathic-scoliosis-screening)
|
|
- Publisher: U.S. Preventive Services Task Force
|
|
- Supports: The forward bend test is commonly used to evaluate adolescents for
|
|
scoliosis, a scoliometer can quantify trunk rotation, and an angle of 5-7
|
|
degrees commonly prompts radiography. The USPSTF concludes that evidence is
|
|
insufficient to determine the benefits and harms of universal screening.
|
|
- Source: [Scoliosis](https://www.srs.org/Patients/Conditions/Scoliosis)
|
|
- Publisher: Scoliosis Research Society
|
|
- Supports: The Adams forward bend test reveals asymmetric rib or lumbar
|
|
prominence and is the most frequently used clinical screening maneuver for
|
|
scoliosis.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-ethics-geriatric-cataract-capacity-923
|
|
|
|
- Source: [Decisions for Adult Patients Who Lack Capacity](https://code-medical-ethics.ama-assn.org/ethics-opinions/decisions-adult-patients-who-lack-capacity)
|
|
- Publisher: American Medical Association Code of Medical Ethics
|
|
- Supports: Patients should participate in decisions according to their
|
|
decision-making capacity; a surrogate exercises authority when the patient
|
|
lacks capacity for the decision, not merely because a cognitive disorder is
|
|
present.
|
|
- Source: [Cataract Surgery](https://www.nei.nih.gov/eye-health-information/eye-conditions-and-diseases/cataracts/cataract-surgery)
|
|
- Publisher: National Eye Institute
|
|
- Supports: Cataract surgery is considered when vision loss interferes with
|
|
everyday activities such as reading; it is common, generally outpatient, and
|
|
improves vision in most patients, although individualized risks must be
|
|
discussed.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-obstetrics-initial-prenatal-blood-type-1024
|
|
|
|
- Source: [Routine Tests During Pregnancy](https://www.acog.org/womens-health/faqs/routine-tests-during-pregnancy)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: Initial prenatal laboratory testing includes maternal blood type and
|
|
Rh status; early identification of Rh-negative patients and alloantibodies
|
|
guides prophylaxis and monitoring.
|
|
- Source: [Screening for Fetal Chromosomal Abnormalities](https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2026/01/screening-for-fetal-chromosomal-abnormalities)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: Cell-free DNA is the most sensitive and specific screening test for
|
|
common fetal aneuploidies and should be made available to all obstetric
|
|
patients after counseling, regardless of baseline risk.
|
|
- Source: [Oocyte or Embryo Donation to Women of Advanced Reproductive Age](https://integration.asrm.org/globalassets/_asrm/practice-guidance/ethics-opinions/pdf/oocyte_or_embryo_donation_to_women_of_advanced_maternal_age_an_ethics_commitee_opinion.pdf)
|
|
- Publisher: American Society for Reproductive Medicine Ethics Committee
|
|
- Supports: In donor-oocyte pregnancies, the incidence of age-related genetic
|
|
abnormalities in offspring relates primarily to the age of the oocyte donor
|
|
rather than the gestational carrier.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-urology-testicular-torsion-811
|
|
|
|
- Source: [AUA Medical Student Curriculum: The Acute Scrotum](https://www.auanet.org/documents/education/Acute-Scrotum.pdf)
|
|
- Publisher: American Urological Association
|
|
- Supports: Definitive treatment of testicular torsion is immediate scrotal
|
|
exploration. The affected testis is detorsed and fixed if viable, and the
|
|
contralateral testis undergoes orchiopexy because the bell-clapper deformity is
|
|
assumed to be bilateral.
|
|
- Source: [Acute Scrotal Pain Clinical Pathway](https://www.hopkinsmedicine.org/-/media/files/allchildrens/clinical-pathways/acute-scrotal-pain-clinical-pathway-12_8_2022.pdf)
|
|
- Publisher: Johns Hopkins All Children's Hospital
|
|
- Supports: Sudden severe pain with a high-riding or transverse testis and absent
|
|
cremasteric reflex can establish torsion clinically and should prompt immediate
|
|
surgical consultation; Doppler ultrasonography is used for equivocal cases.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-pediatrics-hsp-prognosis-517
|
|
|
|
- Source: [IPNA Clinical Practice Recommendations for Children With IgA Nephropathy and IgA Vasculitis Nephritis](https://pmc.ncbi.nlm.nih.gov/articles/PMC11666671/)
|
|
- Publisher: International Pediatric Nephrology Association
|
|
- Supports: Mild IgA vasculitis nephritis with normal blood pressure and kidney
|
|
function can recover without treatment. Persistent proteinuria, particularly
|
|
substantial proteinuria at 1 year, is associated with worse long-term kidney
|
|
prognosis; children with renal involvement require prolonged monitoring.
|
|
- Source: [National Recommendations for the Management of Children and Young People With IgA Vasculitis](https://pmc.ncbi.nlm.nih.gov/articles/PMC11671997/)
|
|
- Publisher: UK Kidney Association-aligned multidisciplinary guideline group
|
|
- Supports: All children with IgA vasculitis require surveillance for nephritis;
|
|
persistent moderate or severe proteinuria, acute kidney injury, and nephrotic
|
|
syndrome identify more severe renal disease requiring additional evaluation.
|
|
- Accessed: 2026-07-12
|
|
- Reviewer: Codex
|
|
|
|
## step3-pediatrics-asthma-environmental-control-388
|
|
|
|
- Source: [Global Strategy for Asthma Management and Prevention, 2025](https://ginasthma.org/wp-content/uploads/2025/07/GINA-2025-Strategy-Report_25_05_25-WMS-2.pdf)
|
|
- Publisher: Global Initiative for Asthma
|
|
- Supports: Parents and caregivers of children with asthma should be advised not
|
|
to smoke or vape and not to permit smoking or vaping in rooms or vehicles used
|
|
by their children; cessation support should be provided.
|
|
- Source: [Asthma and Secondhand Smoke](https://www.cdc.gov/tobacco/campaign/tips/diseases/secondhand-smoke-asthma.html)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Tobacco smoke is a common asthma trigger; families should not smoke
|
|
or allow smoking in the home or car, and opening a window does not protect a
|
|
child from secondhand smoke.
|
|
- Source: [Secondhand Tobacco Smoke and Indoor Air Quality](https://www.epa.gov/indoor-air-quality-iaq/secondhand-tobacco-smoke-and-indoor-air-quality)
|
|
- Publisher: U.S. Environmental Protection Agency
|
|
- Supports: Secondhand smoke causes more frequent and severe asthma attacks in
|
|
children, has no safe exposure level, and cannot be eliminated by ventilation
|
|
or air cleaning.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-infectious-facial-cellulitis-cefazolin-929
|
|
|
|
- Source: [Clinical Guidance for Group A Streptococcal Cellulitis](https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/cellulitis.html)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Nonpurulent cellulitis should receive an antibiotic active against
|
|
streptococci; intravenous options for systemic infection include cefazolin.
|
|
- Source: [Practice Guidelines for Skin and Soft Tissue Infections](https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/)
|
|
- Publisher: Infectious Diseases Society of America
|
|
- Supports: Moderate nonpurulent cellulitis requires systemic antibiotics;
|
|
cefazolin covers streptococci and MSSA, while MRSA coverage is reserved for
|
|
defined risk factors or severe infection.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-hematology-hemophilia-hemarthrosis-928
|
|
|
|
- Source: [WFH Guidelines for the Management of Hemophilia, 3rd Edition: Prophylaxis](https://www1.wfh.org/publications/files/pdf-1907.pdf)
|
|
- Publisher: World Federation of Hemophilia
|
|
- Supports: Children with severe hemophilia should receive early, regular
|
|
prophylaxis; long-term prophylaxis reduces hemarthrosis, slows hemophilic
|
|
arthropathy, and improves joint outcomes compared with episodic treatment.
|
|
- Source: [About Hemophilia](https://www.cdc.gov/hemophilia/about/index.html)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Joint bleeding is a common manifestation of hemophilia and can cause
|
|
chronic joint disease and pain; regular prophylaxis can prevent most bleeding
|
|
episodes.
|
|
- Source: [Testing for Inhibitors and Hemophilia](https://www.cdc.gov/hemophilia/testing/testing-for-inhibitors-and-hemophilia.html)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Factor VIII inhibitors are a separate serious treatment complication
|
|
that can render replacement factor ineffective and warrant regular testing.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-cardiovascular-aaa-surveillance-930
|
|
|
|
- Source: [2022 ACC/AHA Aortic Disease Guideline: Key Perspectives](https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2022/11/01/12/21/2022-Guideline-on-Aortic-Disease-2-gl-ad)
|
|
- Publisher: American College of Cardiology / American Heart Association
|
|
- Supports: Men with an AAA measuring 4.0-4.9 cm should undergo annual
|
|
surveillance; repair is recommended at 5.5 cm or for aneurysm-related symptoms.
|
|
- Source: [Patients with Abdominal Aortic Aneurysm](https://vascular.org/node/87)
|
|
- Publisher: Society for Vascular Surgery
|
|
- Supports: AAA measuring 4.0-4.9 cm should receive surveillance imaging at
|
|
12-month intervals; vascular-surgery referral is recommended at diagnosis.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-gastrointestinal-bowel-obstruction-imaging-731
|
|
|
|
- Source: [ACR Appropriateness Criteria: Suspected Small-Bowel Obstruction](https://acsearch.acr.org/docs/69476/Narrative/)
|
|
- Publisher: American College of Radiology
|
|
- Supports: CT abdomen and pelvis with intravenous contrast is preferred for
|
|
acute suspected obstruction because it identifies the level, cause, bowel
|
|
perfusion, and complications; oral contrast is unnecessary in high-grade SBO.
|
|
- Source: [ASGE Guideline on Colonic Volvulus and Acute Colonic Pseudo-Obstruction](https://www.asge.org/docs/default-source/guidelines/american-society-for-gastrointestinal-endoscopy-guideline-on-the-role-of-endoscopy-in-the-management-of-acute-colonic-pseudo-obstruction-and-colonic-volvulus-2020-february-gie.pdf)
|
|
- Publisher: American Society for Gastrointestinal Endoscopy
|
|
- Supports: Cross-sectional CT distinguishes volvulus, pseudo-obstruction, and
|
|
other mechanical obstruction and has replaced plain radiography as the
|
|
preferred diagnostic study for suspected sigmoid or cecal volvulus.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-preventive-cervical-screening-sexual-orientation-932
|
|
|
|
- Source: [Screening for Cervical Cancer](https://www.acog.org/clinical/clinical-guidance/committee-statement/articles/2026/07/screening-for-cervical-cancer)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: Under the 2026 ACOG/WPSI guidance, average-risk patients age 21-29
|
|
years should receive cervical cytology alone every 3 years.
|
|
- Source: [Women Who Have Sex with Women](https://www.cdc.gov/std/treatment-guidelines/wsw.htm)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: HPV can be transmitted between female partners, and routine cervical
|
|
cancer screening should be offered regardless of sexual orientation or practices.
|
|
- Source: [HPV Infection and Vaccination](https://www.acog.org/womens-health/faqs/hpv-vaccination)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: HPV vaccination does not protect against all HPV types and does not
|
|
remove the need for age-appropriate cervical cancer screening.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-cardiovascular-risk-smoking-841
|
|
|
|
- Source: [Tobacco Smoking Cessation in Adults: Interventions](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions)
|
|
- Publisher: U.S. Preventive Services Task Force
|
|
- Supports: Adults who smoke should receive behavioral interventions and
|
|
FDA-approved pharmacotherapy; the net benefit of cessation treatment is substantial.
|
|
- Source: [Smoking and Cardiovascular Disease](https://www.cdc.gov/tobacco/patient-care/care-settings/pdfs/cdc-osh-hcp-cardio-factsheet-508.pdf)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Smoking cessation improves cardiovascular health, with coronary
|
|
heart disease risk falling sharply within 1-2 years after cessation.
|
|
- Source: [Aspirin Use to Prevent Cardiovascular Disease](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/aspirin-to-prevent-cardiovascular-disease-preventive-medication)
|
|
- Publisher: U.S. Preventive Services Task Force
|
|
- Supports: For adults age 40-59 years with elevated cardiovascular risk,
|
|
aspirin initiation is individualized because the average net benefit is small.
|
|
- Source: [Vitamin and Multivitamin Supplementation to Prevent CVD and Cancer](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-supplementation-to-prevent-cvd-and-cancer-preventive-medication)
|
|
- Publisher: U.S. Preventive Services Task Force
|
|
- Supports: Evidence is insufficient to recommend multivitamins for preventing
|
|
cardiovascular disease, and trials have not shown cardiovascular mortality benefit.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-cardiovascular-exercise-hdl-614
|
|
|
|
- Source: [Physical Activity as First-Line Treatment for Elevated Blood Pressure or Cholesterol](https://professional.heart.org/en/science-news/physical-activity-as-a-critical-component-of-first-line-treatment-for-elevated-bp-or-cholesterol/top-things-to-know)
|
|
- Publisher: American Heart Association
|
|
- Supports: At least 150 minutes of moderate aerobic activity weekly raises HDL
|
|
by about 1-2 mg/dL, lowers LDL by 3-6 mg/dL and triglycerides by 4-12 mg/dL,
|
|
and lowers systolic and diastolic blood pressure by roughly 3-4 mm Hg.
|
|
- Source: [Physical Activity Guidelines for Americans, 2nd Edition](https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf)
|
|
- Publisher: U.S. Department of Health and Human Services
|
|
- Supports: Regular activity improves blood pressure and lipid profiles, and
|
|
substantial cardiovascular benefit occurs at 150 minutes of moderate activity weekly.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-musculoskeletal-lateral-ankle-sprain-935
|
|
|
|
- Source: [Lateral Ankle Ligament Sprains Clinical Practice Guideline](https://www.orthopt.org/uploads/content_files/files/jospt.2021.0302.pdf)
|
|
- Publisher: Academy of Orthopaedic Physical Therapy / Journal of Orthopaedic & Sports Physical Therapy
|
|
- Supports: Acute lateral ankle sprains should receive external support and
|
|
progressive weight bearing; intermittent ice may be used with therapeutic exercise.
|
|
- Source: [ACR Appropriateness Criteria: Acute Trauma to the Ankle](https://acsearch.acr.org/docs/69436/Narrative/)
|
|
- Publisher: American College of Radiology
|
|
- Supports: Ankle radiography is usually not appropriate when Ottawa ankle rules
|
|
are negative, with no relevant bony tenderness and preserved four-step ambulation.
|
|
- Source: [Sprained Ankle](https://orthoinfo.aaos.org/en/diseases--conditions/sprained-ankle/)
|
|
- Publisher: American Academy of Orthopaedic Surgeons
|
|
- Supports: Mild sprains are treated conservatively with early weight bearing,
|
|
removable support when needed, and early functional rehabilitation.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-obstetrics-prenatal-cocaine-exposure-674
|
|
|
|
- Source: [Cocaine](https://www.ncbi.nlm.nih.gov/books/NBK582649/)
|
|
- Publisher: MotherToBaby / Organization of Teratology Information Specialists
|
|
- Supports: Late prenatal cocaine exposure can be followed by irritability,
|
|
tremors, stiffness, poor feeding, sleep disturbance, and hyperactivity; exposure
|
|
also increases risks of low birth weight, prematurity, and placental abruption.
|
|
- Source: [Neonatal Drug Withdrawal](https://publications.aap.org/pediatrics/article/129/2/e540/32573/Neonatal-Drug-Withdrawal)
|
|
- Publisher: American Academy of Pediatrics
|
|
- Supports: Cocaine-exposed neonates can have irritability, hyperactivity,
|
|
tremors, and feeding abnormalities, but a distinct stimulant abstinence
|
|
syndrome is not clearly defined and findings may reflect residual drug effect.
|
|
- Source: [Management of Stillbirth](https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2020/03/management-of-stillbirth)
|
|
- Publisher: American College of Obstetricians and Gynecologists
|
|
- Supports: Maternal cocaine and tobacco use are important contributors to
|
|
placental abruption and stillbirth risk.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-fetal-alcohol-earlyintervention-037
|
|
|
|
- Source: [Treatment of Fetal Alcohol Spectrum Disorders](https://www.cdc.gov/fasd/treatment/index.html)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: Early intervention can improve development; infants and toddlers
|
|
with fetal alcohol syndrome commonly qualify immediately without waiting for
|
|
an established developmental delay.
|
|
- Source: [IDEA Regulation 34 CFR 303.21: Infant or Toddler with a Disability](https://sites.ed.gov/idea/regs/c/a/303.21)
|
|
- Publisher: U.S. Department of Education
|
|
- Supports: Part C eligibility includes diagnosed conditions with a high
|
|
probability of developmental delay and specifically names fetal alcohol syndrome.
|
|
- Source: [IDEA Part C Early Intervention Program](https://www.ed.gov/grants-and-programs/formula-grants/formula-grants-special-populations/idea-early-intervention-program-infants-and-toddlers-disabilities-part-c)
|
|
- Publisher: U.S. Department of Education
|
|
- Supports: Part C provides coordinated, multidisciplinary, family-centered
|
|
services for eligible children from birth through age 2 years.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-congenital-hypothyroidism-adoptedinfant-038
|
|
|
|
- Source: [Congenital Hypothyroidism: Screening and Management](https://publications.aap.org/pediatrics/article/151/1/e2022060419/190311/Congenital-Hypothyroidism-Screening-and-Management)
|
|
- Publisher: American Academy of Pediatrics
|
|
- Supports: Confirmed congenital hypothyroidism requires prompt levothyroxine;
|
|
treatment timing is critical for neurodevelopment, and imaging must never delay therapy.
|
|
- Source: [Congenital Hypothyroidism](https://www.thyroid.org/congenital-hypothyroidism/)
|
|
- Publisher: American Thyroid Association
|
|
- Supports: Low free T4 with elevated TSH confirms primary congenital
|
|
hypothyroidism; levothyroxine is standard treatment with frequent biochemical
|
|
monitoring and pediatric endocrine follow-up.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-delirium-collateral-history-039
|
|
|
|
- Source: [Delirium: prevention, diagnosis and management](https://www.nice.org.uk/guidance/cg103/chapter/Recommendations)
|
|
- Publisher: National Institute for Health and Care Excellence
|
|
- Supports: Recent changes or fluctuations suggesting delirium may be reported
|
|
by a relative or carer; identified cases require formal delirium assessment and
|
|
evaluation and management of contributing causes.
|
|
- Source: [Dementia: assessment, management and support](https://www.nice.org.uk/guidance/ng97/chapter/Recommendations)
|
|
- Publisher: National Institute for Health and Care Excellence
|
|
- Supports: Initial cognitive assessment includes history from the patient and,
|
|
when possible, someone who knows the patient well to characterize cognition,
|
|
behavior, and effects on daily life.
|
|
- Source: [Syphilis: STI Treatment Guidelines](https://www.cdc.gov/std/treatment-guidelines/syphilis.htm)
|
|
- Publisher: Centers for Disease Control and Prevention
|
|
- Supports: A reactive nontreponemal test such as RPR requires confirmation with
|
|
a treponemal test; a single serologic test is insufficient for diagnosis.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-pediatrics-physiologic-anemia-infancy-940
|
|
|
|
- Source: [Well Care for Formerly Preterm Infants](https://publications.aap.org/first1000days/module/27506/section/1cd7f046-cb2d-4e02-b460-4ffc870c33e9)
|
|
- Publisher: American Academy of Pediatrics
|
|
- Supports: Physiologic anemia in term infants reaches a hemoglobin nadir at
|
|
approximately 8-12 weeks, later and at a higher level than in preterm infants.
|
|
- Source: [Perinatal Anemia](https://www.msdmanuals.com/professional/pediatrics/perinatal-hematologic-disorders/perinatal-anemia)
|
|
- Publisher: MSD Manual Professional Edition
|
|
- Supports: Increased oxygenation after birth suppresses erythropoietin and
|
|
erythropoiesis; the shorter neonatal erythrocyte lifespan also contributes to
|
|
the fall over the first 2-3 months, followed by recovery without treatment in
|
|
healthy term infants.
|
|
- Source: [Pathophysiology of Anemia During the Neonatal Period, Including Anemia of Prematurity](https://pmc.ncbi.nlm.nih.gov/articles/PMC2867612/)
|
|
- Publisher: NeoReviews / U.S. National Library of Medicine
|
|
- Supports: Healthy term infants are generally asymptomatic as hemoglobin falls
|
|
to its physiologic nadir at approximately 8-10 weeks and then gradually rises.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-oncology-metastatic-adenocarcinoma-prognosis-941
|
|
|
|
- Source: [Cancer of Unknown Primary Treatment (PDQ), Health Professional Version](https://www.cancer.gov/types/unknown-primary/hp/unknown-primary-treatment-pdq)
|
|
- Publisher: National Cancer Institute
|
|
- Supports: CUP generally has poor prognosis, with approximately 30% of patients
|
|
alive at 1 year; adenocarcinoma histology, older age, hepatic involvement, poor
|
|
performance status, and elevated LDH are associated with worse survival.
|
|
- Source: [SEOM-GECOD Clinical Guideline for Cancer of Unknown Primary, Update 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC13099792/)
|
|
- Publisher: Spanish Society of Medical Oncology / Springer Nature
|
|
- Supports: Approximately 80% of CUP cases belong to an unfavorable subgroup
|
|
with median overall survival of roughly 6-12 months; performance status and LDH
|
|
further refine prognosis, and selected favorable clinicopathologic subsets
|
|
require separate management.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-geriatrics-depression-weightloss-mirtazapine-942
|
|
|
|
- Source: [Unintentional Weight Loss in Older Adults](https://www.aafp.org/pubs/afp/issues/2021/0700/p34.html)
|
|
- Publisher: American Academy of Family Physicians
|
|
- Supports: Mirtazapine can cause appetite increase and weight gain when used to
|
|
treat depression, but evidence does not support prescribing it solely as an
|
|
appetite stimulant; somnolence and dizziness may increase fall risk.
|
|
- Source: [Choosing Wisely](https://www.healthinaging.org/choosing-wisely)
|
|
- Publisher: American Geriatrics Society / Health in Aging Foundation
|
|
- Supports: Avoid prescription appetite stimulants for nonspecific anorexia in
|
|
older adults; megestrol has minimal benefit and increases thrombotic events,
|
|
fluid retention, and death, whereas mirtazapine may increase appetite when it
|
|
is being used for coexisting depression.
|
|
- Source: [American Geriatrics Society 2023 Updated AGS Beers Criteria](https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372)
|
|
- Publisher: American Geriatrics Society
|
|
- Supports: Megestrol should be avoided in older adults because its effect on
|
|
weight is minimal and it increases thrombotic events and possibly death.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-postoperative-fluid-overload-diuresis-943
|
|
|
|
- Source: [Acute Heart Failure: Diagnosis and Management](https://www.nice.org.uk/guidance/cg187/chapter/Recommendations)
|
|
- Publisher: National Institute for Health and Care Excellence
|
|
- Supports: Acute pulmonary congestion should be treated with intravenous loop
|
|
diuretics, with close monitoring of renal function, weight, and urine output;
|
|
ventilatory support is considered when severe respiratory failure or persistent
|
|
distress is present.
|
|
- Source: [2013 ACCF/AHA Guideline for the Management of Heart Failure, Executive Summary](https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools%20and%20Practice%20Support/Quality%20Programs/Heart%20Failure%20Roundtable%202016/Heart%20Failure%20Guidelines/HFG%203%202013%20ACCFAHA%20Guideline.pdf)
|
|
- Publisher: American College of Cardiology / American Heart Association
|
|
- Supports: Hospitalized patients with significant fluid overload should receive
|
|
prompt intravenous loop diuretics, with serial assessment of urine output,
|
|
congestion, renal function, and electrolytes.
|
|
- Source: [Diuretic Therapy for Patients With Heart Failure](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2020/03/09/15/28/Diuretic-Therapy-for-Patients-With-Heart-Failure)
|
|
- Publisher: American College of Cardiology
|
|
- Supports: Loop diuretic dosing is guided by volume status and decongestion;
|
|
renal function changes must be interpreted in the context of persistent congestion.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|
|
|
|
## step3-cardiovascular-white-coat-hypertension-device-check-944
|
|
|
|
- Source: [Home Blood Pressure Monitoring](https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home)
|
|
- Publisher: American Heart Association
|
|
- Supports: Patients should use a validated upper-arm device with the correct
|
|
cuff size, bring it to clinic so accuracy and technique can be checked, and use
|
|
standardized preparation, positioning, and repeated measurements.
|
|
- Source: [Device Calibration Test for Self-Measured Blood Pressure Devices](https://www.ama-assn.org/system/files/2019-04/smbp-device-accuracy-test.pdf)
|
|
- Publisher: American Medical Association
|
|
- Supports: When home results are unreasonably discrepant from office results,
|
|
compare sequential readings from the patient's device and a validated office
|
|
device after confirming proper preparation, positioning, and technique.
|
|
- Source: [Harmonization of ACC/AHA and ESC/ESH Blood Pressure Guidelines](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/08/22/16/48/harmonization-of-the-acc-aha)
|
|
- Publisher: American College of Cardiology
|
|
- Supports: Accurate measurement using validated devices and multiple readings
|
|
is foundational; home or ambulatory monitoring is recommended to identify and
|
|
confirm white-coat and masked blood pressure patterns.
|
|
- Accessed: 2026-07-13
|
|
- Reviewer: Codex
|