202 lines
22 KiB
JSON
202 lines
22 KiB
JSON
{
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"orders": [
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{ "code": "cbc", "canonicalName": "Complete blood count", "category": "laboratory", "aliases": ["cbc", "blood count", "hemoglobin"], "defaultTurnaroundMinutes": 20, "availableLocations": [], "displayRoute": "Blood", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "cmp", "canonicalName": "Comprehensive metabolic panel", "category": "laboratory", "aliases": ["cmp", "chemistry", "bun", "creatinine"], "defaultTurnaroundMinutes": 25, "availableLocations": [], "displayRoute": "Blood", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "iron_studies", "canonicalName": "Iron studies and ferritin", "category": "laboratory", "aliases": ["iron", "ferritin", "transferrin saturation"], "defaultTurnaroundMinutes": 30, "availableLocations": [], "displayRoute": "Blood", "displayFrequency": "Once", "resultSection": "lab" },
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{ "code": "h_pylori_breath", "canonicalName": "Helicobacter pylori urea breath test", "category": "diagnostic", "aliases": ["h pylori", "urea breath test", "helicobacter"], "defaultTurnaroundMinutes": 45, "availableLocations": ["office"], "displayRoute": "Breath", "displayFrequency": "Once", "resultSection": "other_test" },
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{ "code": "upper_endoscopy", "canonicalName": "Upper endoscopy with biopsy", "category": "procedure", "aliases": ["egd", "endoscopy", "gastroscopy", "biopsy"], "defaultTurnaroundMinutes": 60, "availableLocations": ["office"], "displayRoute": "Endoscopic", "displayFrequency": "Once", "resultSection": "other_test" },
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{ "code": "omeprazole", "canonicalName": "Omeprazole acid suppression", "category": "medication", "aliases": ["ppi", "proton pump inhibitor", "acid suppression"], "defaultTurnaroundMinutes": 0, "availableLocations": [], "displayRoute": "Oral", "displayFrequency": "Twice daily", "resultSection": "treatment" },
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{ "code": "bismuth_quadruple", "canonicalName": "Optimized bismuth quadruple therapy for 14 days", "category": "medication", "aliases": ["h pylori treatment", "bismuth", "tetracycline", "metronidazole"], "defaultTurnaroundMinutes": 0, "availableLocations": [], "displayRoute": "Oral", "displayFrequency": "14-day course", "resultSection": "treatment" },
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{ "code": "h_pylori_test_of_cure", "canonicalName": "H. pylori test of cure after therapy", "category": "diagnostic", "aliases": ["test of cure", "repeat breath test", "eradication testing"], "defaultTurnaroundMinutes": 0, "availableLocations": [], "displayRoute": "Outpatient", "displayFrequency": "At least 4 weeks after therapy", "resultSection": "other_test" },
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{ "code": "gastro_follow_up", "canonicalName": "Gastroenterology follow-up", "category": "disposition", "aliases": ["gi follow up", "gastroenterology", "follow-up"], "defaultTurnaroundMinutes": 0, "availableLocations": [], "displayRoute": "Outpatient", "displayFrequency": "Follow-up", "resultSection": "treatment" },
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{ "code": "abdominal_ct", "canonicalName": "CT abdomen and pelvis with contrast", "category": "imaging", "aliases": ["ct abdomen", "cat scan"], "defaultTurnaroundMinutes": 60, "availableLocations": [], "displayRoute": "Imaging", "displayFrequency": "Once", "resultSection": "imaging" },
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{ "code": "clarithromycin_triple", "canonicalName": "Empiric clarithromycin triple therapy", "category": "medication", "aliases": ["clarithromycin", "triple therapy", "prevpac"], "defaultTurnaroundMinutes": 0, "availableLocations": [], "displayRoute": "Oral", "displayFrequency": "14-day course", "resultSection": "treatment" },
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{ "code": "ibuprofen", "canonicalName": "Ibuprofen for abdominal pain", "category": "medication", "aliases": ["nsaid", "motrin", "advil"], "defaultTurnaroundMinutes": 0, "availableLocations": [], "displayRoute": "Oral", "displayFrequency": "As needed", "resultSection": "treatment" }
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],
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"cases": [
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{
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"externalId": "ccs-gastro-duodenal-ulcer-office-001",
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"isPublished": true,
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"title": "Office Visit — 44-year-old man",
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"system": "Gastrointestinal System",
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"presentingLocation": "office",
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"realTimeMinutes": 10,
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"difficulty": 1,
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"tags": ["history taking", "dyspepsia", "duodenal ulcer", "Helicobacter pylori"],
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"experienceMode": "graphical_interview",
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"graphicalPresentation": {
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"sceneKey": "doctor_office",
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"patientAssetKey": "patient_44_white_male",
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"interviewRevision": 4
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},
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"initialChart": {
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"patientSummary": "44-year-old man attending an office visit",
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"reasonForEncounter": "The reason for the visit has not yet been elicited.",
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"appearance": "He is seated comfortably, attentive, and in no acute distress.",
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"history": "Several weeks of intermittent lightheadedness and fatigue accompany three weeks of sleep-disrupting, burning epigastric discomfort rated 4/10. Food and antacids provide temporary relief. He reports belching, fullness, and occasional black stool without frank blood. He has hyperlipidemia and no recent sick contacts, travel, or antibiotic use.",
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"historySections": [
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{ "code": "chief_concern", "title": "Chief concern", "text": "Intermittent lightheadedness and fatigue for several weeks." },
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{ "code": "abdominal_symptoms", "title": "Abdominal symptoms", "text": "Burning, non-radiating epigastric discomfort has been present for three weeks, is rated 4/10, is unaffected by position or movement, and improves temporarily after food or antacids." },
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{ "code": "associated_symptoms", "title": "Associated symptoms", "text": "Belching, fullness, sleep disruption, and occasional black stool without frank blood." },
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{ "code": "past_medical_history", "title": "Past medical history", "text": "Hyperlipidemia" },
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{ "code": "exposure_history", "title": "Exposure history", "text": "No recent sick contacts, travel, or antibiotic use." }
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],
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"vitals": {
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"temperature": "36.8 C (98.2 F)",
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"bloodPressure": "122/76 mm Hg",
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"pulse": "76/min",
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"respirations": "14/min",
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"oxygenSaturation": "99% on room air"
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},
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"simulatedStartUtc": "2026-08-05T09:00:00Z",
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"initialOrderCodes": []
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},
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"initialInterview": {
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"openingPatientText": "Good morning, doctor.",
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"finishChoiceText": "Thank you. I have enough history for now.",
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"closingPatientText": "Thank you, doctor. I hope we can figure out what has been going on.",
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"topics": [
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{
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"id": "chief_concern",
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"clinicianText": "Good morning. What brings you in today?",
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"patientText": "For the past few weeks, I have felt worn out, and every so often I get lightheaded—especially when I stand up quickly.",
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"required": false
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},
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{
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"id": "dizziness_character",
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"clinicianText": "Tell me more about the dizziness. Does the room spin, and have you fainted?",
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"patientText": "The room does not spin. It is more like I might black out for a second when I get up, but I have never actually fainted. I have had no weakness, numbness, trouble speaking, chest pain, or racing heartbeat.",
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"required": true,
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"prerequisiteTopicIds": ["chief_concern"]
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},
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{
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"id": "fatigue_course",
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"clinicianText": "How has the fatigue affected you, and how have you been sleeping and eating?",
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"patientText": "My energy is down by the afternoon. My appetite is about the same, but lately a burning discomfort high in my abdomen sometimes wakes me at night.",
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"required": true,
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"prerequisiteTopicIds": ["chief_concern"]
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},
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{
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"id": "abdominal_character",
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"clinicianText": "Tell me more about the abdominal discomfort—where is it, what does it feel like, and how long has it been happening?",
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"patientText": "It started about three weeks ago. It is a burning pain in the upper middle part of my abdomen. It does not spread anywhere, I would rate it about a four out of ten, and changing position or moving does not make it better or worse.",
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"required": true,
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"prerequisiteTopicIds": ["fatigue_course"]
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},
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{
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"id": "relieving_factors",
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"clinicianText": "Does anything make the discomfort better or worse?",
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"patientText": "Eating usually settles it for a while, and antacids help too. Position and movement do not seem to change it.",
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"required": true,
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"prerequisiteTopicIds": ["abdominal_character"]
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},
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{
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"id": "associated_gi",
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"clinicianText": "Have you noticed belching, fullness, vomiting, or any blood or change in the color of your stool?",
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"patientText": "I have been belching more and sometimes feel unusually full. I have not vomited or seen red blood, but my stool has looked black on occasion.",
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"required": true,
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"prerequisiteTopicIds": ["abdominal_character"]
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},
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{
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"id": "exposure_history",
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"clinicianText": "Have you had any sick contacts, recent travel, or antibiotic use?",
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"patientText": "No. I have not been around anyone sick, traveled recently, or taken antibiotics.",
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"required": true,
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"prerequisiteTopicIds": ["abdominal_character"]
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},
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{
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"id": "past_medical_history",
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"clinicianText": "Do you have any past medical conditions?",
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"patientText": "A few years ago, my doctor told me my cholesterol was high. Other than that, I have not been diagnosed with any major medical problems.",
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"required": false,
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"prerequisiteTopicIds": ["chief_concern"]
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}
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],
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"debrief": {
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"likelyDiagnosis": "Peptic ulcer disease with possible intermittent upper gastrointestinal bleeding",
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"summary": "The history identifies orthostatic lightheadedness and fatigue accompanying burning epigastric pain relieved by food and antacids, with occasional black stool concerning for intermittent upper gastrointestinal bleeding.",
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"teachingPoints": [
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"Clarify whether dizziness is vertigo, presyncope, or disequilibrium and screen for neurologic and cardiac warning symptoms.",
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"Characterize epigastric pain by timing, quality, severity, radiation, triggers, and relieving factors.",
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"Ask specifically about melena or hematemesis because occult or intermittent bleeding can present with fatigue and lightheadedness."
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]
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}
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},
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"allowedLocations": ["office"],
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"exams": [
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{ "code": "physical_appearance", "name": "Physical Appearance", "durationMinutes": 1, "finding": "The patient is alert, cooperative, and in no acute distress. He appears well nourished." },
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{ "code": "skin", "name": "Skin", "durationMinutes": 1, "finding": "Skin is warm and dry without rash, jaundice, bruising, or visible pallor." },
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{ "code": "breasts", "name": "Breasts", "durationMinutes": 1, "finding": "With the patient's consent and a chaperone present, examination shows no masses, tenderness, skin changes, or nipple discharge." },
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{ "code": "lymph_nodes", "name": "Lymph Nodes", "durationMinutes": 1, "finding": "No cervical, supraclavicular, axillary, or inguinal lymphadenopathy is present." },
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{ "code": "heent_neck", "name": "HEENT / Neck", "durationMinutes": 1, "finding": "Conjunctivae and oral mucosa are normal. Oropharynx is clear, neck is supple, and there is no thyromegaly or jugular venous distention." },
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{ "code": "chest_lungs", "name": "Chest / Lungs", "durationMinutes": 1, "finding": "Breathing is unlabored. Lungs are clear to auscultation bilaterally without wheezes, crackles, or rhonchi." },
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{ "code": "heart_cardiovascular", "name": "Heart / Cardiovascular", "durationMinutes": 1, "finding": "Heart has a regular rate and rhythm with normal S1 and S2 and no murmurs, rubs, or gallops. Peripheral pulses are symmetric." },
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{ "code": "abdomen", "name": "Abdomen", "durationMinutes": 1, "finding": "The abdomen is soft and nondistended with mild epigastric tenderness. There is no guarding, rebound tenderness, palpable mass, or hepatosplenomegaly. Bowel sounds are normal." },
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{ "code": "genitalia", "name": "Genitalia", "durationMinutes": 1, "finding": "With the patient's consent and a chaperone present, external genital examination is normal without lesions, masses, tenderness, or hernia." },
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{ "code": "rectal", "name": "Rectal", "durationMinutes": 1, "finding": "With the patient's consent and a chaperone present, rectal tone is normal and no mass or tenderness is present. Brown stool without gross blood is noted." },
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{ "code": "extremities_spine", "name": "Extremities / Spine", "durationMinutes": 1, "finding": "Extremities have full range of motion without edema, clubbing, cyanosis, or joint swelling. The spine is nontender." },
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{ "code": "neuro_psych", "name": "Neuro / Psych", "durationMinutes": 1, "finding": "He is alert and fully oriented with normal speech, strength, sensation, coordination, gait, mood, and affect." }
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],
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"orderResponses": [
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{ "orderCode": "cbc", "turnaroundMinutes": 20, "result": "Hemoglobin is 10.4 g/dL, hematocrit 32%, MCV 74 fL, leukocyte count 7,100/mm3, and platelet count 312,000/mm3.", "resultSection": "lab" },
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{ "orderCode": "cmp", "turnaroundMinutes": 25, "result": "BUN is 27 mg/dL and creatinine 1.0 mg/dL. Electrolytes, glucose, aminotransferases, bilirubin, and albumin are within reference ranges.", "resultSection": "lab" },
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{ "orderCode": "iron_studies", "turnaroundMinutes": 30, "result": "Ferritin is 10 ng/mL, serum iron 31 mcg/dL, and transferrin saturation 9%, supporting iron deficiency.", "resultSection": "lab" },
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{ "orderCode": "h_pylori_breath", "turnaroundMinutes": 45, "result": "Urea breath test is positive for Helicobacter pylori.", "resultSection": "other_test" },
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{ "orderCode": "upper_endoscopy", "turnaroundMinutes": 60, "result": "Upper endoscopy shows an 8 mm clean-based ulcer in the duodenal bulb without active bleeding. Gastric biopsy is positive for H. pylori and shows no dysplasia or malignancy.", "resultSection": "other_test" },
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{ "orderCode": "omeprazole", "turnaroundMinutes": 0, "result": "Proton-pump inhibitor therapy is started.", "resultSection": "treatment" },
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{ "orderCode": "bismuth_quadruple", "turnaroundMinutes": 0, "result": "A 14-day optimized bismuth quadruple regimen is prescribed.", "resultSection": "treatment" },
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{ "orderCode": "h_pylori_test_of_cure", "turnaroundMinutes": 0, "result": "Test-of-cure follow-up is scheduled for at least four weeks after therapy, with PPI held for two weeks before testing.", "resultSection": "treatment" },
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{ "orderCode": "gastro_follow_up", "turnaroundMinutes": 0, "result": "Gastroenterology follow-up is arranged to review healing, anemia, and eradication testing.", "resultSection": "treatment" },
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{ "orderCode": "abdominal_ct", "turnaroundMinutes": 60, "result": "CT of the abdomen and pelvis shows no acute intra-abdominal abnormality.", "resultSection": "imaging" },
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{ "orderCode": "clarithromycin_triple", "turnaroundMinutes": 0, "result": "Empiric clarithromycin-based therapy is prescribed without susceptibility confirmation.", "resultSection": "treatment" },
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{ "orderCode": "ibuprofen", "turnaroundMinutes": 0, "result": "Ibuprofen is prescribed despite suspected peptic ulcer disease and possible gastrointestinal bleeding.", "resultSection": "treatment" }
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],
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"events": [],
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"scoringCriteria": [
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{ "id": "elicit_chief_concern", "title": "Elicit the chief concern", "actionType": "dialogue_choice", "targetCode": "chief_concern", "points": 10, "rationale": "An open-ended opening allows the patient to identify lightheadedness and fatigue in his own words." },
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{ "id": "characterize_dizziness", "title": "Characterize the dizziness", "actionType": "dialogue_choice", "targetCode": "dizziness_character", "points": 15, "rationale": "Distinguishing presyncope from vertigo and screening for neurologic and cardiac warning symptoms focuses the differential." },
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{ "id": "explore_fatigue", "title": "Explore fatigue, sleep, and intake", "actionType": "dialogue_choice", "targetCode": "fatigue_course", "points": 10, "rationale": "The course and associated symptoms help characterize the nonspecific fatigue." },
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{ "id": "characterize_abdominal_pain", "title": "Characterize the abdominal discomfort", "actionType": "dialogue_choice", "targetCode": "abdominal_character", "points": 15, "rationale": "Location, quality, duration, severity, and radiation help characterize the source of pain." },
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{ "id": "identify_relief", "title": "Identify relieving and aggravating factors", "actionType": "dialogue_choice", "targetCode": "relieving_factors", "points": 10, "rationale": "Temporary relief with food or antacids supports an acid-related pattern." },
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{ "id": "screen_gi_bleeding", "title": "Screen for gastrointestinal bleeding", "actionType": "dialogue_choice", "targetCode": "associated_gi", "points": 15, "rationale": "Occasional black stool may represent melena and requires recognition." },
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{ "id": "review_exposures", "title": "Review relevant exposures", "actionType": "dialogue_choice", "targetCode": "exposure_history", "points": 5, "rationale": "Recent illness, travel, and antibiotic exposure help refine the gastrointestinal differential." },
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{ "id": "assess_appearance", "title": "Assess physical appearance", "actionType": "exam", "targetCode": "physical_appearance", "points": 5, "rationale": "General appearance helps assess acuity and physiologic compromise." },
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{ "id": "examine_skin", "title": "Examine the skin", "actionType": "exam", "targetCode": "skin", "points": 5, "rationale": "Skin examination screens for pallor, jaundice, bruising, and other systemic clues." },
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{ "id": "examine_lungs", "title": "Examine the chest and lungs", "actionType": "exam", "targetCode": "chest_lungs", "points": 5, "rationale": "A cardiopulmonary examination helps evaluate associated fatigue and lightheadedness." },
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{ "id": "examine_heart", "title": "Examine the cardiovascular system", "actionType": "exam", "targetCode": "heart_cardiovascular", "points": 5, "rationale": "Cardiovascular examination helps assess presyncope and hemodynamic status." },
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{ "id": "examine_abdomen", "title": "Examine the abdomen", "actionType": "exam", "targetCode": "abdomen", "points": 15, "rationale": "Focused abdominal examination identifies epigastric tenderness and screens for peritoneal signs or masses." },
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{ "id": "perform_rectal_exam", "title": "Perform a rectal examination", "actionType": "exam", "targetCode": "rectal", "points": 10, "rationale": "Rectal examination can assess for current gross gastrointestinal bleeding when the history includes black stool." },
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{ "id": "perform_neurologic_exam", "title": "Perform a neurologic examination", "actionType": "exam", "targetCode": "neuro_psych", "points": 5, "rationale": "A focused neurologic examination helps evaluate lightheadedness and exclude focal deficits." },
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{ "id": "check_cbc", "title": "Assess anemia with a CBC", "actionType": "order", "targetCode": "cbc", "points": 12, "rationale": "Fatigue, lightheadedness, and intermittent melena warrant assessment for blood-loss anemia." },
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{ "id": "check_iron", "title": "Confirm iron deficiency", "actionType": "order", "targetCode": "iron_studies", "points": 6, "rationale": "Iron studies characterize the microcytic anemia." },
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{ "id": "test_h_pylori", "title": "Test for H. pylori", "actionType": "order", "targetCode": "h_pylori_breath", "points": 12, "rationale": "H. pylori testing identifies a treatable cause of peptic ulcer disease." },
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{ "id": "perform_egd", "title": "Evaluate suspected bleeding with upper endoscopy", "actionType": "order", "targetCode": "upper_endoscopy", "points": 12, "rationale": "Endoscopy confirms the ulcer and evaluates bleeding risk." },
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{ "id": "start_ppi", "title": "Begin proton-pump inhibitor therapy", "actionType": "order", "targetCode": "omeprazole", "points": 8, "rationale": "Acid suppression promotes ulcer healing." },
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{ "id": "eradicate_h_pylori", "title": "Treat H. pylori appropriately", "actionType": "order", "targetCode": "bismuth_quadruple", "points": 15, "afterTargetCode": "h_pylori_breath", "rationale": "Optimized bismuth quadruple therapy is an appropriate empiric eradication regimen." },
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{ "id": "confirm_eradication", "title": "Arrange H. pylori test of cure", "actionType": "order", "targetCode": "h_pylori_test_of_cure", "points": 8, "afterTargetCode": "bismuth_quadruple", "rationale": "Eradication should be confirmed after treatment." },
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{ "id": "avoid_clarithromycin", "title": "Avoid unsupported clarithromycin triple therapy", "actionType": "order", "targetCode": "clarithromycin_triple", "points": -8, "rationale": "Empiric clarithromycin therapy should be avoided without demonstrated susceptibility." },
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{ "id": "avoid_nsaid", "title": "Avoid NSAIDs", "actionType": "order", "targetCode": "ibuprofen", "points": -12, "rationale": "NSAIDs may worsen ulcer injury and gastrointestinal bleeding." }
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],
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"references": [
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{
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"title": "Peptic Ulcer Disease",
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"publisher": "American College of Gastroenterology",
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"url": "https://gi.org/topics/peptic-ulcer-disease/",
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"supports": "Typical ulcer symptoms, bleeding warning symptoms, NSAID history, H. pylori evaluation, and endoscopic diagnosis",
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"accessedOn": "2026-08-05",
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"reviewer": "Question bank editorial review"
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},
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{
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"title": "ACG Guideline on Treatment of Helicobacter pylori: New Recommendations",
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"publisher": "American College of Gastroenterology",
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"url": "https://gi.org/journals-publications/ebgi/schoenfeld_sep2024/",
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"supports": "H. pylori treatment principles and confirmation of eradication",
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"accessedOn": "2026-08-05",
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"reviewer": "Question bank editorial review"
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}
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]
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}
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],
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"validateOnly": false
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}
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