step3/tools/Difficulty4GapSeeder20260730/SeedCatalog.cs

internal static class SeedCatalog
{
    internal static readonly Seed[] All =
    [
        new("acute-compartment-syndrome-fasciotomy", "Musculoskeletal System", "Surgery", "Musculoskeletal/Skin & Subcutaneous Tissue", "compartment syndrome",
            "A 34-year-old man has escalating lower-leg pain after tibial fracture fixation. The pain is severe with passive toe extension. The anterior compartment is tense, pedal pulses remain palpable, and analgesics no longer provide relief.",
            "Which is the most appropriate next step?",
            ["Immediate four-compartment fasciotomy", "CT angiography of the leg", "Elevation above heart level and observation", "Increase opioid analgesia", "Wait for loss of pedal pulses", "Serial creatine kinase measurement without decompression"],
            "Progressive pain with passive stretch and a tense compartment after fracture indicates acute compartment syndrome. Definitive treatment is immediate complete fasciotomy; palpable pulses do not exclude dangerous compartment pressure.",
            "Treat clinically apparent acute compartment syndrome with urgent complete decompression before irreversible muscle and nerve injury occurs.",
            "Waiting for pulselessness diagnoses a late, limb-threatening stage.",
            "pain is severe with passive toe extension", "pedal pulses remain palpable", "the anterior compartment is tense",
            "Palpable pulses exclude compartment syndrome", "Imaging should delay decompression until vascular injury is proven",
            "Management of Acute Compartment Syndrome", "American Academy of Orthopaedic Surgeons", "https://www.aaos.org/acscpg2025", "Diagnosis and urgent complete fasciotomy for acute compartment syndrome."),

        new("diabetic-foot-osteomyelitis-bone-culture", "Musculoskeletal System", "Medicine", "Musculoskeletal/Skin & Subcutaneous Tissue", "diabetic foot osteomyelitis",
            "A 62-year-old man with diabetes has an ulcer beneath the first metatarsal head that probes to bone. Plain radiographs show cortical erosion. A superficial swab grows mixed skin flora, he is hemodynamically stable, and no drainable abscess is present.",
            "Which test best identifies the pathogen responsible for the suspected osteomyelitis?",
            ["Percutaneous or intraoperative bone culture", "Repeat superficial swab culture", "Serum procalcitonin alone", "Blood culture after antibiotics", "Tagged leukocyte scan without tissue sampling", "Empiric lifelong antibiotics without microbiologic sampling"],
            "When diabetic foot osteomyelitis is suspected, a bone specimen rather than a superficial soft-tissue swab provides the most reliable microbiologic diagnosis and guides targeted therapy.",
            "Obtain bone for culture when defining the causative organism in diabetic foot osteomyelitis.",
            "Superficial wound flora may not represent organisms infecting bone.",
            "probes to bone", "a superficial swab grows mixed skin flora", "no drainable abscess is present",
            "A superficial swab reliably identifies bone pathogens", "Imaging alone supplies antimicrobial susceptibility data",
            "IWGDF/IDSA Guidelines on Diabetes-Related Foot Infections", "Infectious Diseases Society of America", "https://www.idsociety.org/practice-guideline/diabetic-foot-infections/", "Bone rather than soft-tissue sampling for suspected diabetic foot osteomyelitis."),

        new("native-septic-arthritis-drainage", "Musculoskeletal System", "Medicine", "Musculoskeletal/Skin & Subcutaneous Tissue", "septic arthritis",
            "A 71-year-old woman receiving adalimumab develops abrupt knee pain and inability to bear weight. The knee is warm with a large effusion. Arthrocentesis yields opaque fluid with gram-positive cocci, blood pressure is stable, and radiographs show no fracture.",
            "Which management is most appropriate?",
            ["Prompt joint drainage plus intravenous antibiotics", "Intra-articular glucocorticoid injection", "Oral colchicine alone", "Delay treatment for final culture susceptibilities", "Physical therapy without antimicrobial treatment", "Arthroscopic inspection without drainage or antibiotics"],
            "Purulent synovial fluid with organisms establishes septic arthritis. Rapid antimicrobial therapy and evacuation of infected joint fluid are needed to limit cartilage destruction and systemic spread.",
            "Septic arthritis requires prompt antimicrobial treatment and drainage of the infected joint.",
            "Immunosuppression can blunt systemic findings despite destructive joint infection.",
            "arthrocentesis yields opaque fluid with gram-positive cocci", "blood pressure is stable", "radiographs show no fracture",
            "Stable blood pressure permits delayed treatment", "Steroid injection is safe before infection is controlled",
            "Guideline for Management of Septic Arthritis in Native Joints", "European Bone and Joint Infection Society", "https://jbji.copernicus.org/articles/8/29/2023/", "Prompt drainage and antimicrobial therapy for native-joint septic arthritis."),

        new("open-fracture-early-antibiotics", "Musculoskeletal System", "Emergency Medicine", "Musculoskeletal/Skin & Subcutaneous Tissue", "open fracture",
            "A 27-year-old motorcyclist has a tibial fracture with bone visible through a contaminated wound. Distal perfusion is intact. Sterile saline-moistened dressing and splinting are applied, tetanus status is unknown, and operative irrigation is being arranged.",
            "Which intervention should occur immediately?",
            ["Administer systemic antibiotic prophylaxis", "Close the wound primarily in the emergency department", "Delay antibiotics until operative cultures return", "Probe the wound repeatedly to assess depth", "Apply a circumferential cast over the wound", "Provide tetanus prophylaxis as the only infection-prevention measure"],
            "An open fracture is contaminated at presentation. Systemic antibiotics should be administered as early as possible, alongside tetanus prophylaxis and urgent operative debridement planning.",
            "Give early systemic antibiotics for an open fracture; do not wait for operative cultures or debridement.",
            "A sterile dressing protects the wound but does not replace antimicrobial prophylaxis.",
            "bone visible", "distal perfusion is intact", "operative irrigation is being arranged",
            "Intact perfusion eliminates infection risk", "Cultures must precede the first antibiotic dose",
            "Prevention of Surgical Site Infections After Major Extremity Trauma", "American Academy of Orthopaedic Surgeons", "https://www.aaos.org/surgical-site-infections-after-major-extremity-trauma/", "Early antibiotic prophylaxis and operative management of open extremity fractures."),

        new("dermatomyositis-malignancy-screening", "Musculoskeletal System", "Rheumatology", "Musculoskeletal/Skin & Subcutaneous Tissue", "dermatomyositis",
            "A 58-year-old woman has progressive proximal weakness, a violaceous eyelid eruption, and scaly papules over the knuckles. Electromyography supports inflammatory myopathy. She has unintentional weight loss, routine age-appropriate screening is incomplete, and there is no medication trigger.",
            "Which additional evaluation is most important?",
            ["Risk-stratified screening for occult malignancy", "Testing only for Lyme disease", "Immediate muscle biopsy before any cancer evaluation", "Reassurance that the condition is never paraneoplastic", "Long-term antibiotics for presumed cellulitis", "Repeat electromyography yearly without age-appropriate screening"],
            "Adult-onset dermatomyositis is associated with malignancy, particularly near disease onset. Clinical risk assessment and appropriate enhanced plus age- and sex-based screening are indicated.",
            "Evaluate adults with newly diagnosed dermatomyositis for occult malignancy using risk-stratified screening.",
            "Cancer evaluation complements rather than replaces confirmation and treatment of inflammatory myopathy.",
            "progressive proximal weakness", "she has unintentional weight loss", "scaly papules over the knuckles",
            "Dermatomyositis has no association with malignancy", "Cancer screening should wait until weakness resolves",
            "International Guideline for Idiopathic Inflammatory Myopathy-Associated Cancer Screening", "International Myositis Assessment and Clinical Studies Group", "https://www.nature.com/articles/s41584-023-01045-w", "Risk-stratified malignancy screening in adults with idiopathic inflammatory myopathy."),

        new("prosthetic-joint-acute-da-ir", "Musculoskeletal System", "Surgery", "Musculoskeletal/Skin & Subcutaneous Tissue", "prosthetic joint infection",
            "A 66-year-old man develops acute pain and drainage from a knee arthroplasty placed 3 weeks ago. Symptoms began 2 days ago. The implant is stable, the soft-tissue envelope is intact, aspiration grows methicillin-susceptible Staphylococcus aureus, and there is no sinus tract.",
            "Which surgical strategy is most appropriate?",
            ["Debridement with implant retention and modular-component exchange", "No surgery because the implant is stable", "Immediate amputation", "Chronic suppressive antibiotics without source control", "Delay intervention until the prosthesis loosens"],
            "A stable, recently implanted prosthesis with very short symptom duration and no sinus tract is a setting in which debridement, antibiotics, implant retention, and exchange of modular components can be appropriate.",
            "Early acute prosthetic-joint infection with a stable implant requires prompt source control; selected patients can undergo debridement and implant retention.",
            "A sinus tract or prolonged symptoms would make retention less likely to succeed.",
            "symptoms began 2 days ago", "the implant is stable", "there is no sinus tract",
            "Stable hardware means surgery is unnecessary", "Waiting for loosening improves implant-retention success",
            "Diagnosis and Management of Prosthetic Joint Infection", "Infectious Diseases Society of America", "https://www.idsociety.org/practice-guideline/prosthetic-joint-infection/", "Selection of debridement and implant retention for early acute prosthetic-joint infection."),

        new("cauda-equina-urgent-decompression", "Musculoskeletal System", "Surgery", "Nervous System & Special Senses", "cauda equina syndrome",
            "A 49-year-old warehouse worker with a known lumbar disk herniation develops bilateral leg weakness and numbness around the perineum. He cannot initiate urination, rectal tone is reduced, and symptoms progressed over 6 hours.",
            "Which is the most appropriate next step?",
            ["Emergency lumbar MRI and surgical decompression", "Routine outpatient physical therapy", "Lumbar epidural steroid injection before imaging", "Oral analgesics with follow-up in one month", "Electromyography before spinal imaging", "Bladder training before evaluating the spinal canal"],
            "Acute urinary retention, saddle anesthesia, reduced rectal tone, and bilateral deficits indicate cauda equina syndrome. Emergency MRI and prompt decompression are required.",
            "Treat suspected cauda equina syndrome as a surgical emergency requiring immediate imaging and decompression.",
            "Do not attribute new bladder dysfunction to pain medication without excluding compressive neurologic injury.",
            "he cannot initiate urination", "rectal tone is reduced", "bilateral leg weakness",
            "Outpatient therapy is appropriate despite bladder dysfunction", "Electrodiagnostic testing should precede emergency imaging",
            "Suspected Neurological Conditions: Cauda Equina Syndrome", "National Institute for Health and Care Excellence", "https://www.nice.org.uk/guidance/ng127", "Emergency recognition and referral for cauda equina syndrome."),

        new("rhabdomyolysis-volume-resuscitation", "Musculoskeletal System", "Emergency Medicine", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "rhabdomyolysis",
            "A 41-year-old man is rescued after his thigh was compressed beneath machinery for 7 hours. Urine is dark, the thigh is swollen but compartments remain soft, electrocardiography shows no hyperkalemic changes, and he is making urine.",
            "Which intervention best reduces the risk of acute kidney injury?",
            ["Early intravenous isotonic crystalloid resuscitation", "Routine bicarbonate and mannitol for every patient", "Fluid restriction", "Immediate dialysis despite preserved urine output", "High-dose loop diuretics as sole therapy", "Delay fluids until urine myoglobin is quantified"],
            "Crush-related rhabdomyolysis releases myoglobin and causes intravascular depletion. Early goal-directed isotonic crystalloid is the primary kidney-protective treatment.",
            "Early isotonic crystalloid resuscitation is central to preventing rhabdomyolysis-associated acute kidney injury.",
            "Bicarbonate, mannitol, and diuretics are not routine substitutes for adequate volume resuscitation.",
            "urine is dark", "he is making urine", "compartments remain soft",
            "Preserved urine output eliminates kidney-injury risk", "Routine mannitol is superior to crystalloid",
            "Rhabdomyolysis Clinical Consensus Document", "American Association for the Surgery of Trauma", "https://pmc.ncbi.nlm.nih.gov/articles/PMC8804685/", "Fluid resuscitation and renal-protection strategy in rhabdomyolysis."),

        new("neonatal-hsv-empiric-acyclovir", "Nervous System", "Pediatrics", "Nervous System & Special Senses", "neonatal herpes",
            "A 12-day-old infant has poor feeding, focal seizures, and grouped vesicles on the scalp. The mother had no recognized genital lesions. Cerebrospinal fluid testing is pending, the infant remains perfused, and bacterial cultures have been collected.",
            "Which treatment should be started now?",
            ["Intravenous acyclovir", "Wait for polymerase-chain-reaction confirmation", "Topical acyclovir only", "Oral valacyclovir", "Glucocorticoids without antiviral therapy", "Phototherapy for the vesicular eruption"],
            "Neonatal herpes can rapidly cause encephalitis or disseminated disease, and maternal history is often absent. Empiric intravenous acyclovir should begin immediately when clinical findings suggest infection.",
            "Start empiric intravenous acyclovir promptly when neonatal herpes is suspected; do not await confirmatory testing.",
            "Absence of known maternal lesions does not meaningfully exclude neonatal HSV.",
            "focal seizures", "grouped vesicles on the scalp", "the mother had no recognized genital lesions",
            "Maternal history reliably excludes neonatal HSV", "Topical therapy treats suspected neonatal encephalitis",
            "Sexually Transmitted Infections Treatment Guidelines: Genital Herpes", "Centers for Disease Control and Prevention", "https://www.cdc.gov/std/treatment-guidelines/herpes.htm", "Recognition and intravenous acyclovir treatment of neonatal herpes."),

        new("pediatric-intussusception-air-enema", "Gastrointestinal System", "Pediatrics", "Gastrointestinal System", "intussusception",
            "A 10-month-old boy has episodic screaming with leg flexion and vomiting. Between episodes he appears tired. Ultrasonography shows a target-shaped ileocolic mass. The abdomen has no guarding, there is no free air, and he is hemodynamically stable.",
            "Which is the most appropriate next step?",
            ["Pneumatic enema reduction", "Immediate laparotomy without attempted reduction", "Upper endoscopy", "Oral laxatives and discharge", "Observation for spontaneous resolution"],
            "Stable ileocolic intussusception without perforation or peritonitis is treated with image-guided pneumatic or hydrostatic enema reduction.",
            "Use enema reduction first for uncomplicated, stable ileocolic intussusception.",
            "Perforation, peritonitis, shock, or failed enema reduction requires operative management.",
            "ultrasonography shows a target-shaped ileocolic mass", "there is no free air", "he is hemodynamically stable",
            "Every intussusception requires immediate laparotomy", "A stable child should be observed without reduction",
            "Management of Intussusception in Children", "American College of Radiology", "https://acsearch.acr.org/docs/69451/Narrative/", "Imaging diagnosis and enema reduction of uncomplicated pediatric intussusception."),

        new("pyloric-stenosis-correct-electrolytes", "Gastrointestinal System", "Pediatrics", "Gastrointestinal System", "pyloric stenosis",
            "A 5-week-old boy has progressive projectile nonbilious vomiting and visible gastric peristalsis. Ultrasonography confirms hypertrophic pyloric stenosis. He is dehydrated, capillary refill is delayed, and a chloride-responsive metabolic alkalosis is present.",
            "Which is the most appropriate next step?",
            ["Intravenous fluid and electrolyte correction before pyloromyotomy", "Immediate pyloromyotomy before resuscitation", "Emergency bowel resection", "Oral feeding challenge", "Acid suppression alone"],
            "Pyloric stenosis requires pyloromyotomy, but the metabolic and volume abnormalities must first be corrected because the operation is urgent rather than immediately emergent.",
            "Resuscitate and correct electrolyte abnormalities before pyloromyotomy for hypertrophic pyloric stenosis.",
            "The nonbilious character localizes obstruction proximal to the duodenum but does not eliminate anesthetic risk from alkalosis.",
            "projectile nonbilious vomiting", "he is dehydrated", "a chloride-responsive metabolic alkalosis is present",
            "Surgery must precede correction of dehydration", "Acid suppression reverses muscular hypertrophy",
            "Appropriateness Criteria: Vomiting in Infants", "American College of Radiology", "https://acsearch.acr.org/docs/69445/Narrative/", "Diagnosis and stabilization priorities in infantile hypertrophic pyloric stenosis."),

        new("pediatric-dka-cerebral-injury-hyperosmolar", "Endocrine System", "Pediatrics", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "pediatric DKA",
            "A 13-year-old girl is receiving protocolized treatment for diabetic ketoacidosis. Six hours later she develops severe headache, bradycardia, declining consciousness, and new urinary incontinence. Her glucose is falling gradually, blood pressure is preserved, and no sedating medication was given.",
            "Which treatment should be administered immediately?",
            ["Hypertonic saline or mannitol for suspected cerebral injury", "Increase the insulin infusion sharply", "Administer intravenous bicarbonate routinely", "Obtain lumbar puncture before treatment", "Stop all intravenous fluids permanently", "Wait for head CT confirmation before osmotherapy"],
            "Neurologic deterioration with headache and bradycardia during pediatric DKA treatment indicates cerebral injury. Hyperosmolar therapy should be given immediately without waiting for imaging.",
            "Treat suspected cerebral injury during pediatric DKA immediately with hypertonic saline or mannitol.",
            "A gradual glucose decline does not exclude DKA-related cerebral injury.",
            "she develops severe headache", "bradycardia", "declining consciousness",
            "Imaging confirmation must precede hyperosmolar therapy", "More insulin reverses cerebral edema",
            "Diabetes in Children and Young People: Recommendations", "National Institute for Health and Care Excellence", "https://www.nice.org.uk/guidance/ng18/chapter/Recommendations", "Recognition and emergency hyperosmolar treatment of cerebral edema during pediatric DKA."),

        new("sickle-acute-chest-exchange-transfusion", "Respiratory System", "Pediatrics", "Respiratory System", "acute chest syndrome",
            "A 16-year-old boy with sickle cell disease is admitted for acute chest syndrome. Despite oxygen, antibiotics, incentive spirometry, and simple transfusion, hypoxemia worsens and pulmonary infiltrates progress to multiple lobes. He is tachypneic, hemoglobin has risen after transfusion, and respiratory effort is increasing.",
            "Which treatment is most appropriate now?",
            ["Urgent red-cell exchange transfusion", "Repeat simple transfusions without limit", "Discontinue antibiotics", "Therapeutic phlebotomy alone", "Delay escalation until mechanical ventilation is required"],
            "Rapidly progressive, severe acute chest syndrome despite initial therapy is an indication for exchange transfusion, which lowers the sickle hemoglobin fraction without excessive viscosity.",
            "Use exchange transfusion for severe or rapidly progressive acute chest syndrome.",
            "Repeated simple transfusion after hemoglobin has risen can increase viscosity.",
            "hypoxemia worsens", "pulmonary infiltrates progress to multiple lobes", "hemoglobin has risen after transfusion",
            "Exchange transfusion should wait for intubation", "Higher viscosity improves pulmonary perfusion",
            "ASH Guidelines for Sickle Cell Disease: Transfusion Support", "American Society of Hematology", "https://ashpublications.org/bloodadvances/article/4/2/327/440607/American-Society-of-Hematology-2020-guidelines-for", "Exchange transfusion for severe acute chest syndrome."),

        new("child-abuse-sentinel-injury-evaluation", "Multisystem", "Pediatrics", "Behavioral Health & Social Sciences: Communication, Ethics, Patient Safety", "child abuse",
            "A 4-month-old nonmobile infant is brought for a small bruise on the cheek. The caregiver reports that the infant rolled into a table, but developmental history confirms he cannot roll. A healing posterior rib fracture is seen incidentally, the infant is calm, and the caregiver asks to leave.",
            "Which is the most appropriate next step?",
            ["Initiate a complete abuse evaluation and ensure immediate safety", "Discharge because the bruise is small", "Wait for another injury before reporting concern", "Confront the caregiver and permit departure", "Document only the current bruise", "Ask the caregiver to arrange outpatient skeletal imaging", "Report only if the caregiver confesses"],
            "Bruising in a nonmobile infant and a posterior rib fracture are sentinel injuries highly concerning for inflicted trauma. The clinician must evaluate for occult injury, report suspicion, and establish safety.",
            "Sentinel injuries in a nonmobile infant require prompt evaluation for abuse and immediate protection.",
            "A benign appearance does not exclude occult intracranial, skeletal, or abdominal injury.",
            "a small bruise on the cheek", "he cannot roll", "a healing posterior rib fracture",
            "Minor bruising in a nonmobile infant is expected", "Reporting requires proof rather than reasonable suspicion",
            "Child Maltreatment: A Guide for Prevention", "Centers for Disease Control and Prevention", "https://www.cdc.gov/child-abuse-neglect/about/index.html", "Recognition, reporting, and safety response to suspected child maltreatment."),

        new("pediatric-septic-hip-aspiration", "Musculoskeletal System", "Pediatrics", "Musculoskeletal/Skin & Subcutaneous Tissue", "pediatric septic arthritis",
            "A 6-year-old boy refuses to bear weight and holds the hip flexed and externally rotated. He has acute pain with passive motion and an effusion on ultrasonography. Blood cultures are obtained, there was no trauma, and inflammatory markers are markedly elevated.",
            "Which is the most appropriate next step?",
            ["Urgent joint aspiration followed by drainage and antibiotics", "Discharge with ibuprofen for transient synovitis", "Intra-articular glucocorticoid injection", "Wait one week for repeat ultrasonography", "Begin physical therapy"],
            "The inability to bear weight, painful restricted motion, effusion, and inflammation make septic arthritis likely. Prompt aspiration for microbiology and urgent drainage plus antibiotics protect the joint.",
            "Suspected bacterial arthritis of the hip requires urgent aspiration and source control.",
            "Transient synovitis should not be assumed when high-risk inflammatory features are present.",
            "refuses to bear weight", "an effusion on ultrasonography", "inflammatory markers are markedly elevated",
            "Ultrasonographic effusion proves transient synovitis", "Antibiotics should wait a week in a stable child",
            "PIDS/IDSA Guideline for Acute Bacterial Arthritis in Pediatrics", "Infectious Diseases Society of America", "https://www.idsociety.org/practice-guideline/acute-bacterial-arthritis-in-pediatrics2/", "Diagnostic aspiration, drainage, and antimicrobial treatment of pediatric bacterial arthritis."),

        new("neonatal-bilious-emesis-volvulus", "Gastrointestinal System", "Pediatrics", "Gastrointestinal System", "malrotation volvulus",
            "A 3-day-old newborn develops sudden bilious emesis and abdominal distention. He becomes lethargic with poor perfusion. The abdomen is tender, the anus is patent, and prenatal ultrasonography was normal.",
            "Which is the most appropriate next step?",
            ["Immediate surgical consultation and operative management for volvulus", "Discharge after changing formula", "Pyloromyotomy", "Barium enema as definitive treatment", "Observe until stool passage"],
            "Bilious vomiting with shock and abdominal tenderness in a neonate suggests midgut volvulus from malrotation. Resuscitation and emergency operative evaluation must not be delayed.",
            "Treat a neonate with suspected midgut volvulus as a surgical emergency.",
            "Normal prenatal imaging does not exclude malrotation.",
            "sudden bilious emesis", "poor perfusion", "the abdomen is tender",
            "Bilious emesis is typical of pyloric stenosis", "Normal prenatal imaging excludes volvulus",
            "Appropriateness Criteria: Vomiting in Infants", "American College of Radiology", "https://acsearch.acr.org/docs/69445/Narrative/", "Emergency evaluation of neonatal bilious vomiting and suspected malrotation with volvulus."),

        new("acute-angle-closure-immediate-pressure-lowering", "Eye & Adnexa", "Ophthalmology", "Nervous System & Special Senses", "angle closure glaucoma",
            "A 64-year-old woman develops severe unilateral eye pain, headache, nausea, and halos after entering a dark theater. The affected eye is red with a cloudy cornea and a fixed mid-dilated pupil. Visual acuity is reduced, there was no trauma, and the other eye is comfortable.",
            "Which is the most appropriate immediate management?",
            ["Rapid medical lowering of intraocular pressure followed by laser iridotomy", "Topical antibiotic drops only", "Eye patching and outpatient observation", "Immediate cataract refraction", "Systemic glucocorticoids alone"],
            "This is acute angle-closure glaucoma, an ophthalmic emergency. Pressure-lowering medications are started immediately, followed by definitive laser peripheral iridotomy when the cornea and pressure permit.",
            "Acute angle closure requires immediate intraocular-pressure reduction and definitive iridotomy.",
            "A fixed mid-dilated pupil with a cloudy painful eye is not uncomplicated conjunctivitis.",
            "a fixed mid-dilated pupil", "the affected eye is red", "visual acuity is reduced",
            "Antibiotic drops open the anterior chamber angle", "Observation prevents optic-nerve ischemia",
            "Primary Angle Closure Disease Preferred Practice Pattern", "American Academy of Ophthalmology", "https://www.aao.org/education/preferred-practice-pattern/primary-angle-closure-disease-ppp", "Emergency pressure reduction and definitive iridotomy for acute angle closure."),

        new("retinal-detachment-urgent-repair", "Eye & Adnexa", "Ophthalmology", "Nervous System & Special Senses", "retinal detachment",
            "A 59-year-old highly myopic man reports flashes, many new floaters, and a curtain descending across the right visual field. The eye is painless. Dilated examination shows a superior retinal tear with detachment approaching the macula, central acuity remains intact, and there is no redness.",
            "Which is the most appropriate next step?",
            ["Same-day retinal-surgery evaluation for repair", "Routine optometry appointment in six months", "Topical antibiotics", "Carotid endarterectomy", "Reassurance for ocular migraine"],
            "A symptomatic retinal tear with a macula-threatening detachment requires urgent retinal specialist repair to preserve central vision.",
            "Urgently repair a macula-on or macula-threatening retinal detachment.",
            "Painless symptoms do not make a retinal detachment benign.",
            "a curtain descending across the right visual field", "the eye is painless", "central acuity remains intact",
            "Intact central acuity permits routine follow-up", "Topical therapy reattaches the retina",
            "Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration PPP", "American Academy of Ophthalmology", "https://www.aao.org/education/preferred-practice-pattern/posterior-vitreous-detachment-retinal-breaks-latti", "Urgent evaluation and repair of symptomatic retinal tears and detachment."),

        new("orbital-cellulitis-iv-antibiotics-imaging", "Eye & Adnexa", "Pediatrics", "Nervous System & Special Senses", "orbital cellulitis",
            "A 9-year-old child with recent sinusitis has eyelid swelling, pain with eye movement, proptosis, and reduced color vision. The child is ill appearing, visual acuity has declined, there is no penetrating trauma, and the opposite eye is normal.",
            "Which is the most appropriate management?",
            ["Hospitalize for intravenous antibiotics and urgent orbital imaging", "Treat with topical antibiotic drops at home", "Prescribe an oral antihistamine", "Patch the eye and reassess in one week", "Perform tonometry only"],
            "Painful extraocular movement, proptosis, and visual dysfunction indicate postseptal orbital cellulitis. Hospitalization, broad intravenous antibiotics, imaging, and ophthalmologic and ENT assessment are required.",
            "Orbital signs or visual compromise require inpatient intravenous therapy and urgent imaging.",
            "Preseptal cellulitis does not cause proptosis, ophthalmoplegia, or impaired vision.",
            "pain with eye movement", "proptosis", "reduced color vision",
            "Topical drops treat postseptal infection", "Proptosis is typical of allergic swelling",
            "Orbital Cellulitis", "American Academy of Ophthalmology", "https://eyewiki.aao.org/Orbital_Cellulitis", "Recognition, imaging, intravenous antibiotics, and surgical indications for orbital cellulitis."),

        new("chemical-eye-injury-immediate-irrigation", "Eye & Adnexa", "Emergency Medicine", "Nervous System & Special Senses", "chemical eye injury",
            "A laboratory worker splashes an alkaline cleaning solution into both eyes. He has intense pain, blepharospasm, and blurred vision. Coworkers bring the product label, contact lenses remain in place, and the exposure occurred 5 minutes ago.",
            "Which action has the highest priority?",
            ["Begin immediate copious ocular irrigation", "Measure visual acuity before any treatment", "Neutralize the alkali with an acid", "Wait for an ophthalmologist before irrigation", "Apply topical anesthetic and discharge", "Cover both eyes until the product safety sheet is reviewed"],
            "Chemical ocular injury demands immediate copious irrigation. Treatment begins before a complete examination; contact lenses are removed during irrigation and pH is checked serially.",
            "Do not delay irrigation of a chemical eye exposure for examination, consultation, or agent identification.",
            "Attempting chemical neutralization can generate heat and worsen injury.",
            "an alkaline cleaning solution", "the exposure occurred 5 minutes ago", "contact lenses remain in place",
            "Visual acuity must precede irrigation", "An acid should be applied to neutralize alkali",
            "Chemical Injury of the Conjunctiva and Cornea", "American Academy of Ophthalmology", "https://eyewiki.aao.org/Chemical_%28Alkali_and_Acid%29_Injury_of_the_Conjunctiva_and_Cornea", "Immediate irrigation and initial management of ocular chemical burns."),

        new("posterior-epistaxis-airway-packing", "Ear, Nose & Throat", "Emergency Medicine", "Nervous System & Special Senses", "posterior epistaxis",
            "A 76-year-old man taking apixaban has brisk bleeding into the posterior pharynx from both nostrils. Direct pressure and topical vasoconstrictor have failed. He is coughing blood, blood pressure is falling, and no anterior bleeding point is visible.",
            "Which is the most appropriate next step?",
            ["Protect the airway and place posterior nasal packing with specialist consultation", "Discharge with humidification", "Continue pinching the nasal bridge indefinitely", "Perform lumbar puncture", "Start intranasal glucocorticoids"],
            "Ongoing bilateral posterior bleeding with hemodynamic compromise threatens the airway. Resuscitation, airway protection as needed, posterior packing or balloon control, reversal assessment, and urgent specialist management are required.",
            "Severe posterior epistaxis requires airway and hemodynamic stabilization plus definitive posterior control.",
            "Posterior packing requires monitored admission because of rebleeding and airway risk.",
            "brisk bleeding into the posterior pharynx", "blood pressure is falling", "no anterior bleeding point is visible",
            "Failure to see an anterior point makes discharge safe", "Humidification controls hemorrhagic shock",
            "Clinical Practice Guideline: Nosebleed", "American Academy of Otolaryngology–Head and Neck Surgery", "https://www.entnet.org/quality-practice/quality-products/clinical-practice-guidelines/cpg-nosebleed/", "Escalation, packing, and specialist management for severe epistaxis."),

        new("peritonsillar-abscess-drainage", "Ear, Nose & Throat", "Medicine", "Nervous System & Special Senses", "peritonsillar abscess",
            "A 24-year-old woman has worsening unilateral throat pain, trismus, drooling, and a muffled voice. The uvula is displaced away from a bulging tonsillar pillar. She can maintain the airway, oxygenation is normal, and there is no neck trauma.",
            "Which management is most appropriate?",
            ["Drain the abscess and administer antibiotics", "Treat with throat lozenges alone", "Begin anticoagulation", "Perform immediate thyroidectomy", "Wait for spontaneous rupture without monitoring"],
            "Trismus, muffled voice, uvular deviation, and a unilateral peritonsillar bulge indicate peritonsillar abscess. Drainage plus antimicrobial therapy is standard when the airway is currently stable.",
            "Peritonsillar abscess generally requires drainage and antibiotics while airway risk is assessed.",
            "Drooling or worsening respiratory distress would require immediate airway escalation.",
            "the uvula is displaced", "she can maintain the airway", "a bulging tonsillar pillar",
            "Antibiotics are never needed after drainage", "Stable oxygenation makes source control unnecessary",
            "Pharyngitis and Tonsillitis Including Peritonsillar Abscess", "Oxford University Hospitals NHS Foundation Trust", "https://ouh.quris.com/hospital-guidelines/adult-antimicrobial-guide/empiric-treatment/ent-and-orofacial/pharyngitistonsillitis-including-peritonsillar-abscess-and-group-a-strep-throat-infection/", "Urgent ENT evaluation, source control, and antibiotics for peritonsillar abscess."),

        new("cryptococcal-meningitis-raised-pressure", "Immune System", "Infectious Disease", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "cryptococcal meningitis",
            "A 38-year-old man with advanced HIV has cryptococcal meningitis and is receiving liposomal amphotericin plus flucytosine. He develops worsening headache and vomiting. Repeat lumbar puncture shows markedly elevated opening pressure, neurologic examination is otherwise unchanged, and brain imaging shows no mass lesion.",
            "Which intervention is most appropriate?",
            ["Therapeutic lumbar puncture to reduce intracranial pressure", "Acetazolamide as sole therapy", "Routine glucocorticoids", "Stop antifungal therapy", "Place a permanent shunt before attempting serial drainage", "Mannitol without cerebrospinal-fluid drainage"],
            "Raised intracranial pressure is a major cause of morbidity in cryptococcal meningitis. Symptomatic elevation requires prompt therapeutic lumbar puncture, often repeated daily.",
            "Measure and aggressively manage raised opening pressure with therapeutic lumbar puncture in cryptococcal meningitis.",
            "Acetazolamide, mannitol, and routine corticosteroids do not replace cerebrospinal-fluid drainage.",
            "markedly elevated opening pressure", "worsening headache", "brain imaging shows no mass lesion",
            "Antifungal therapy alone immediately normalizes pressure", "Routine steroids are first-line pressure treatment",
            "Global Guideline for the Diagnosis and Management of Cryptococcosis", "Infectious Diseases Society of America", "https://www.idsociety.org/practice-guideline/Diagnosis-and-Management-of-Cryptococcosis/", "Induction therapy and management of raised intracranial pressure in cryptococcal meningitis."),

        new("pcp-hypoxemia-adjunctive-steroids", "Respiratory System", "Infectious Disease", "Respiratory System", "pneumocystis pneumonia",
            "A 45-year-old man with untreated HIV has subacute dyspnea, dry cough, and diffuse bilateral ground-glass opacities. Pneumocystis testing is positive. His resting oxygenation demonstrates a severe gas-exchange impairment, he is not receiving glucocorticoids, and there is no bacterial consolidation.",
            "Which addition to trimethoprim-sulfamethoxazole is indicated?",
            ["Adjunctive systemic glucocorticoids", "Inhaled bronchodilator only", "Immediate antiretroviral therapy as the sole pneumonia treatment", "Loop diuresis", "Therapeutic anticoagulation"],
            "Moderate-to-severe Pneumocystis pneumonia with substantial hypoxemia benefits from early adjunctive corticosteroids in addition to antimicrobial therapy.",
            "Add corticosteroids early for HIV-associated Pneumocystis pneumonia with moderate-to-severe hypoxemia.",
            "Antiretroviral therapy is important but does not replace acute antimicrobial and adjunctive treatment.",
            "diffuse bilateral ground-glass opacities", "a severe gas-exchange impairment", "Pneumocystis testing is positive",
            "Steroids are used only after antimicrobial failure", "Antiretroviral therapy alone clears acute pneumonia",
            "Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults With HIV", "National Institutes of Health", "https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/pneumocystis", "Adjunctive corticosteroid indications in moderate-to-severe Pneumocystis pneumonia."),

        new("septic-shock-antibiotics-source-control", "Multisystem", "Emergency Medicine", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "septic shock",
            "A 68-year-old woman with obstructive pyelonephritis remains hypotensive after initial crystalloid resuscitation. Cultures have been drawn, broad-spectrum antibiotics are available, an obstructing ureteral stone is confirmed, and urology is at the bedside.",
            "Which combined strategy is most appropriate now?",
            ["Prompt antibiotics, norepinephrine, and urgent urinary decompression", "Delay antibiotics until culture speciation", "Continue unlimited crystalloid without vasopressor", "Treat with glucocorticoids alone", "Schedule outpatient stone removal", "Start vasopressin monotherapy without drainage", "Give diuretics to increase urine flow through the obstruction"],
            "Septic shock requires prompt effective antimicrobials, norepinephrine when hypotension persists after initial fluids, and rapid control of an anatomic infection source such as an obstructed collecting system.",
            "Treat septic shock simultaneously with antimicrobials, hemodynamic support, and timely source control.",
            "No amount of vasopressor support substitutes for drainage of an infected obstruction.",
            "remains hypotensive after initial crystalloid resuscitation", "an obstructing ureteral stone is confirmed", "urology is at the bedside",
            "Culture speciation should precede antibiotics in shock", "Vasopressors eliminate the need for source control",
            "Surviving Sepsis Campaign Adult Guidelines", "Society of Critical Care Medicine", "https://www.sccm.org/survivingsepsiscampaign/guidelines-and-resources/surviving-sepsis-campaign-adult-guidelines", "Prompt antimicrobials, norepinephrine, and source control in septic shock."),

        new("severe-malaria-iv-artesunate", "Multisystem", "Infectious Disease", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "severe malaria",
            "A 32-year-old traveler returning from West Africa has confusion, jaundice, and Plasmodium falciparum parasitemia. He cannot take oral medication. Kidney function is worsening, blood glucose is being monitored, and no alternative diagnosis explains the illness.",
            "Which treatment should be started immediately?",
            ["Intravenous artesunate", "Oral chloroquine", "Doxycycline monotherapy", "Exchange transfusion without antimalarial therapy", "Wait for species confirmation at a reference laboratory"],
            "Falciparum malaria with altered mental status and organ dysfunction is severe malaria. Intravenous artesunate should be started immediately while additional doses and follow-on oral therapy are arranged.",
            "Treat severe malaria immediately with intravenous artesunate.",
            "Treatment should not wait for confirmatory testing when severe falciparum malaria is identified.",
            "confusion", "he cannot take oral medication", "kidney function is worsening",
            "Oral monotherapy is adequate despite organ dysfunction", "Reference-laboratory confirmation should delay therapy",
            "Treatment of Severe Malaria", "Centers for Disease Control and Prevention", "https://www.cdc.gov/malaria/hcp/clinical-guidance/treatment-of-severe-malaria.html", "Immediate intravenous artesunate for severe malaria."),

        new("prosthetic-valve-endocarditis-surgery", "Cardiovascular System", "Infectious Disease", "Cardiovascular System", "infective endocarditis",
            "A 70-year-old man with a prosthetic aortic valve has persistent Staphylococcus aureus bacteremia despite appropriate antibiotics. Transesophageal echocardiography shows a mobile vegetation and a new periannular abscess. He has new conduction delay, coronary angiography is not urgently needed, and there is no intracranial hemorrhage.",
            "Which is the most appropriate next step?",
            ["Urgent cardiac surgical evaluation while antibiotics continue", "Complete antibiotics before considering surgery", "Stop antibiotics and repeat cultures next month", "Begin thrombolysis", "Treat with anticoagulation alone", "Remove the prosthesis percutaneously without surgical planning"],
            "Prosthetic-valve endocarditis with persistent bacteremia, periannular abscess, and conduction abnormality indicates uncontrolled invasive infection and is a strong indication for urgent surgery.",
            "Seek early surgery for endocarditis complicated by abscess, uncontrolled infection, or prosthetic-valve involvement.",
            "New conduction disease suggests extension near the conduction system.",
            "persistent Staphylococcus aureus bacteremia", "a new periannular abscess", "new conduction delay",
            "Antibiotics reliably sterilize every periannular abscess", "Surgery should always wait until antibiotics are complete",
            "Infective Endocarditis in Adults", "American Heart Association", "https://www.ahajournals.org/doi/10.1161/CIR.0000000000000296", "Surgical indications for prosthetic-valve endocarditis and periannular abscess."),

        new("meningitis-dexamethasone-before-antibiotics", "Nervous System", "Infectious Disease", "Nervous System & Special Senses", "bacterial meningitis",
            "A 57-year-old asplenic man has abrupt headache, neck stiffness, confusion, and purpuric lesions. Blood cultures are obtained. Lumbar puncture will be delayed for neuroimaging, empiric antibiotics are ready, and he has no antibiotic allergy.",
            "Which adjunctive treatment should be given with the first antibiotic dose?",
            ["Dexamethasone", "Acyclovir as the only antimicrobial", "Mannitol routinely", "Therapeutic heparin", "Delay all treatment until lumbar puncture"],
            "When pneumococcal bacterial meningitis is possible, dexamethasone should be administered before or with the first antibiotic dose. Imaging or lumbar puncture delays must not delay antimicrobial treatment.",
            "Give dexamethasone before or with initial antibiotics when bacterial meningitis is suspected and pneumococcus is possible.",
            "Dexamethasone started after multiple antibiotic doses is less likely to provide benefit.",
            "neck stiffness", "lumbar puncture will be delayed", "empiric antibiotics are ready",
            "Lumbar puncture must precede every treatment", "Steroids replace bactericidal antibiotics",
            "Practice Guidelines for the Management of Bacterial Meningitis", "Infectious Diseases Society of America", "https://www.idsociety.org/practice-guideline/bacterial-meningitis/", "Timing of dexamethasone and empiric antibiotics in suspected bacterial meningitis."),

        new("tumor-lysis-rasburicase", "Hematologic System", "Hematology", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "tumor lysis syndrome",
            "A 19-year-old man with bulky Burkitt lymphoma develops acute kidney injury and arrhythmia shortly after chemotherapy. He has marked hyperuricemia, phosphate elevation, and hypocalcemia. Intravenous fluids are running, urine output is falling, and no obstructive uropathy is present.",
            "Which medication should be administered urgently?",
            ["Rasburicase", "Allopurinol as the only treatment for existing severe hyperuricemia", "Calcium routinely despite no tetany", "Hydrochlorothiazide", "Oral iron", "Probenecid despite acute kidney injury"],
            "Established high-risk tumor lysis syndrome with severe hyperuricemia and acute kidney injury requires rapid uric-acid degradation with rasburicase in addition to fluids and electrolyte management.",
            "Use rasburicase for established or high-risk tumor lysis with substantial hyperuricemia.",
            "Allopurinol prevents new uric acid formation but does not rapidly remove uric acid already present.",
            "marked hyperuricemia", "urine output is falling", "no obstructive uropathy is present",
            "Allopurinol rapidly degrades existing uric acid", "Asymptomatic hypocalcemia should always be corrected aggressively",
            "Rasburicase Expert Review for the Essential Medicines List", "World Health Organization", "https://cdn.who.int/media/docs/default-source/essential-medicines/2021-eml-expert-committee/expert-reviews/a27_rasburicase_rev1.pdf?sfvrsn=12301379_8", "Rasburicase treatment of severe hyperuricemia associated with tumor lysis syndrome."),

        new("malignancy-hypercalcemia-calcitonin-bisphosphonate", "Endocrine System", "Oncology", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "hypercalcemia of malignancy",
            "A 65-year-old woman with metastatic breast cancer has confusion, constipation, profound dehydration, and severe symptomatic hypercalcemia. Isotonic intravenous fluid has begun. Kidney function permits antiresorptive therapy, there is no heart failure, and the electrocardiogram shows a shortened QT interval.",
            "Which pharmacologic treatment is most appropriate now?",
            ["Calcitonin plus an intravenous bisphosphonate", "Thiazide diuretic", "Vitamin D supplementation", "Observation after fluids only", "Teriparatide"],
            "Severe symptomatic hypercalcemia of malignancy needs rapid temporary calcium reduction with calcitonin plus durable antiresorptive treatment such as an intravenous bisphosphonate.",
            "Combine calcitonin for rapid effect with antiresorptive therapy for severe hypercalcemia of malignancy.",
            "Calcitonin alone develops tachyphylaxis and should not be relied on for durable control.",
            "severe symptomatic hypercalcemia", "profound dehydration", "kidney function permits antiresorptive therapy",
            "Thiazides increase urinary calcium excretion", "Calcitonin alone provides durable control",
            "Treatment of Hypercalcemia of Malignancy in Adults", "Endocrine Society", "https://www.endocrine.org/clinical-practice-guidelines/hypercalcemia-of-malignancy", "Calcitonin and antiresorptive therapy for severe hypercalcemia of malignancy."),

        new("malignant-spinal-cord-compression", "Nervous System", "Oncology", "Nervous System & Special Senses", "spinal cord compression",
            "A 68-year-old man with metastatic prostate cancer develops severe thoracic back pain, progressive leg weakness, and urinary hesitancy. Examination shows a sensory level and hyperreflexia. Symptoms progressed overnight, he can still move both legs, and no fever is present.",
            "Which is the most appropriate immediate management?",
            ["Administer dexamethasone and obtain emergency spinal MRI", "Schedule routine radiographs next week", "Perform lumbar puncture", "Start physical therapy only", "Wait for complete paralysis before imaging", "Obtain a bone scan before treating cord compression"],
            "Cancer with new pain, myelopathic deficits, and bladder symptoms indicates metastatic spinal cord compression. Dexamethasone and urgent whole-spine MRI should be initiated while definitive radiation or surgery is arranged.",
            "Suspected malignant spinal cord compression requires immediate glucocorticoids and emergency MRI.",
            "Neurologic function at treatment strongly predicts functional outcome.",
            "progressive leg weakness", "a sensory level", "urinary hesitancy",
            "Imaging can wait while some movement remains", "Lumbar puncture defines epidural compression",
            "Spinal Metastases and Metastatic Spinal Cord Compression", "National Institute for Health and Care Excellence", "https://www.nice.org.uk/guidance/ng234", "Immediate corticosteroids, MRI, and definitive management of metastatic spinal cord compression."),

        new("acute-promyelocytic-leukemia-atra", "Hematologic System", "Hematology", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "acute promyelocytic leukemia",
            "A 31-year-old woman has gingival bleeding, bruising, and pancytopenia. The smear shows abnormal promyelocytes with multiple Auer rods. Coagulation studies indicate disseminated intravascular coagulation, molecular confirmation is pending, and she has no prior leukemia treatment.",
            "Which treatment should be started immediately?",
            ["All-trans retinoic acid", "Wait for molecular confirmation before therapy", "Warfarin", "Platelet transfusion as the only treatment", "Imatinib", "Delay leukemia therapy until the coagulopathy resolves spontaneously"],
            "Suspected acute promyelocytic leukemia with coagulopathy is a medical emergency. All-trans retinoic acid should begin immediately on morphologic suspicion because early hemorrhagic death can occur.",
            "Start all-trans retinoic acid immediately when acute promyelocytic leukemia is suspected.",
            "Do not wait for genetic confirmation before initiating ATRA in a compatible presentation.",
            "multiple Auer rods", "disseminated intravascular coagulation", "molecular confirmation is pending",
            "Molecular confirmation must precede ATRA", "Anticoagulation treats the leukemia-associated coagulopathy",
            "Management of Acute Promyelocytic Leukemia", "European LeukemiaNet", "https://ashpublications.org/blood/article/133/15/1630/275931/Management-of-acute-promyelocytic-leukemia-updated", "Immediate ATRA for suspected acute promyelocytic leukemia."),

        new("acute-leukemia-leukostasis-leukapheresis", "Hematologic System", "Hematology", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem", "leukostasis",
            "A 46-year-old man with newly diagnosed acute myeloid leukemia develops confusion, hypoxemia, and diffuse pulmonary opacities. The peripheral blood has extreme leukocytosis dominated by blasts. There is no focal infection, blood viscosity symptoms are progressing, and definitive induction planning is underway.",
            "Which immediate strategy is most appropriate?",
            ["Urgent cytoreduction with supportive tumor-lysis prevention", "Red-cell transfusion to raise viscosity", "Observation until induction starts next week", "Platelet inhibition alone", "Therapeutic anticoagulation"],
            "Neurologic and pulmonary dysfunction with extreme blast leukocytosis indicates leukostasis. Immediate cytoreduction, commonly hydroxyurea with consideration of leukapheresis, and tumor-lysis prophylaxis are required.",
            "Treat symptomatic leukostasis as an emergency with immediate cytoreduction and tumor-lysis prevention.",
            "Do not delay cytoreduction while completing the full leukemia classification.",
            "confusion", "hypoxemia", "extreme leukocytosis dominated by blasts",
            "Leukostasis is asymptomatic by definition", "Higher blood viscosity improves tissue oxygenation",
            "Acute Myeloid Leukemia: ESMO Clinical Practice Guidelines", "European Society for Medical Oncology", "https://www.annalsofoncology.org/article/S0923-7534(20)36079-8/fulltext", "Emergency cytoreduction for symptomatic hyperleukocytosis in acute myeloid leukemia."),

        new("papillary-muscle-rupture-emergency-surgery", "Cardiovascular System", "Cardiology", "Cardiovascular System", "mechanical MI complication",
            "A 73-year-old man develops sudden pulmonary edema and shock 3 days after an inferior myocardial infarction. A new loud systolic murmur is present. Echocardiography shows a flail mitral leaflet with severe acute regurgitation, the ventricular septum is intact, and vasopressor support has begun.",
            "Which definitive management is most appropriate?",
            ["Emergency mitral-valve surgery", "Outpatient diuretic adjustment", "Thrombolysis as sole treatment", "Observation for spontaneous papillary-muscle healing", "Permanent pacemaker placement"],
            "Papillary-muscle rupture causes catastrophic acute mitral regurgitation after myocardial infarction. Stabilization is a bridge to emergency surgical repair or replacement.",
            "Acute severe mitral regurgitation from papillary-muscle rupture requires emergency surgery.",
            "The posteromedial papillary muscle is vulnerable after inferior infarction because it often has a single blood supply.",
            "a flail mitral leaflet", "severe acute regurgitation", "the ventricular septum is intact",
            "Medical therapy definitively repairs papillary rupture", "Pacemaker placement corrects acute regurgitation",
            "2021 Guideline for Coronary Artery Revascularization", "American College of Cardiology and American Heart Association", "https://www.ahajournals.org/doi/10.1161/CIR.0000000000001038", "Emergency surgery for mechanical complications after myocardial infarction."),

        new("symptomatic-severe-aortic-stenosis-replacement", "Cardiovascular System", "Cardiology", "Cardiovascular System", "aortic stenosis",
            "An 82-year-old man has exertional syncope, angina, and dyspnea. Echocardiography confirms severe calcific aortic stenosis with preserved ventricular function. Symptoms are attributable to the valve, estimated survival exceeds one year, and a multidisciplinary valve team considers transfemoral access feasible.",
            "Which treatment offers the best outcome?",
            ["Aortic-valve replacement after shared valve-team assessment", "Exercise training alone", "Long-term nitrate escalation", "Balloon valvuloplasty as definitive routine therapy", "Observation until ventricular function declines"],
            "Symptomatic severe aortic stenosis has a poor prognosis without valve replacement. In an older patient, the heart team selects transcatheter or surgical replacement according to anatomy, risk, life expectancy, and preferences.",
            "Valve replacement is indicated for symptomatic severe aortic stenosis.",
            "Preserved ejection fraction does not justify delaying treatment when classic symptoms are present.",
            "exertional syncope", "severe calcific aortic stenosis", "transfemoral access feasible",
            "Preserved ventricular function eliminates the need for replacement", "Vasodilators reverse fixed valvular obstruction",
            "2020 Guideline for the Management of Patients With Valvular Heart Disease", "American College of Cardiology and American Heart Association", "https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923", "Indications and modality selection for aortic-valve replacement."),

        new("preexcited-af-procainamide", "Cardiovascular System", "Emergency Medicine", "Cardiovascular System", "preexcited atrial fibrillation",
            "A 28-year-old man with Wolff-Parkinson-White pattern develops palpitations. Electrocardiography shows an irregular wide-complex tachycardia with beat-to-beat variation. Blood pressure is stable, he is alert, no ischemic pain is present, and defibrillation equipment is ready.",
            "Which medication is most appropriate?",
            ["Intravenous procainamide", "Intravenous adenosine", "Intravenous diltiazem", "Intravenous digoxin", "Intravenous metoprolol", "Intravenous verapamil", "Carotid sinus massage"],
            "Stable preexcited atrial fibrillation requires an agent such as procainamide that slows the accessory pathway. AV-nodal blockers can preferentially route conduction down the pathway and precipitate ventricular fibrillation.",
            "Avoid AV-nodal blockers in preexcited atrial fibrillation; use procainamide when stable and cardioversion when unstable.",
            "An irregular wide-complex rhythm in a patient with preexcitation is not treated like routine narrow-complex SVT.",
            "an irregular wide-complex tachycardia", "blood pressure is stable", "Wolff-Parkinson-White pattern",
            "Adenosine safely blocks every accessory pathway", "Diltiazem prevents pathway-mediated ventricular activation",
            "2023 Guideline for Diagnosis and Management of Atrial Fibrillation", "American College of Cardiology and American Heart Association", "https://www.ahajournals.org/doi/10.1161/CIR.0000000000001193", "Treatment of atrial fibrillation with ventricular preexcitation."),

        new("cardiac-tamponade-urgent-drainage", "Cardiovascular System", "Cardiology", "Cardiovascular System", "cardiac tamponade",
            "A 55-year-old woman with metastatic lung cancer develops dyspnea, hypotension, jugular venous distention, and pulsus paradoxus. Echocardiography shows a large pericardial effusion with right-ventricular diastolic collapse. She remains unstable after cautious fluid administration, no tension pneumothorax is present, and platelets are adequate.",
            "Which is the most appropriate next step?",
            ["Urgent pericardial drainage", "Aggressive diuresis", "Positive-pressure ventilation before drainage", "Observation with repeat imaging next week", "Systemic thrombolysis", "Increase beta-blocker therapy"],
            "Hemodynamic compromise plus chamber collapse indicates cardiac tamponade. Urgent pericardiocentesis or surgical drainage is required.",
            "Drain the pericardium urgently when tamponade causes hemodynamic instability.",
            "Positive-pressure ventilation and diuresis can further reduce preload before decompression.",
            "right-ventricular diastolic collapse", "she remains unstable", "a large pericardial effusion",
            "Diuresis improves preload-dependent tamponade", "Echocardiographic chamber collapse can be observed despite shock",
            "2015 Guidelines for the Diagnosis and Management of Pericardial Diseases", "European Society of Cardiology", "https://academic.oup.com/eurheartj/article/36/42/2921/2293378", "Urgent drainage for unstable cardiac tamponade."),

        new("acute-mesenteric-ischemia-cta", "Gastrointestinal System", "Surgery", "Gastrointestinal System", "mesenteric ischemia",
            "A 74-year-old woman with atrial fibrillation develops abrupt severe periumbilical pain. Early abdominal examination shows little tenderness. Lactate is rising, she has no contrast allergy, kidney function is acceptable, and there is no free intraperitoneal air.",
            "Which diagnostic study should be obtained immediately?",
            ["CT angiography of the abdomen and pelvis", "Routine colonoscopy", "Noncontrast abdominal radiography only", "Barium enema", "Elective magnetic resonance imaging next month", "Repeat lactate after analgesia before imaging"],
            "Pain out of proportion in a patient with an embolic risk suggests acute mesenteric ischemia. CT angiography is the rapid diagnostic test of choice and should not be delayed for nonspecific laboratory testing.",
            "Obtain urgent CT angiography when acute mesenteric ischemia is suspected.",
            "A benign early abdominal examination does not exclude evolving bowel infarction.",
            "abrupt severe periumbilical pain", "atrial fibrillation", "little tenderness",
            "Minimal tenderness excludes bowel ischemia", "Colonoscopy is the fastest test for mesenteric arterial occlusion",
            "Acute Mesenteric Ischemia Guidelines", "World Society of Emergency Surgery", "https://wjes.biomedcentral.com/articles/10.1186/s13017-022-00443-x", "Immediate CT angiography and management of acute mesenteric ischemia."),

        new("toxic-megacolon-surgical-escalation", "Gastrointestinal System", "Surgery", "Gastrointestinal System", "toxic megacolon",
            "A 39-year-old man with ulcerative colitis is hospitalized for toxic megacolon. Despite intensive intravenous glucocorticoids and supportive care, abdominal distention worsens and he develops increasing tenderness and shock. Colonic dilation persists, broad-spectrum antibiotics are running, and there is no clinical improvement.",
            "Which is the most appropriate next step?",
            ["Urgent subtotal colectomy with end ileostomy", "Colonoscopy with full bowel preparation", "Escalate opioid analgesics", "Discharge on oral mesalamine", "Continue medical therapy indefinitely", "Administer an antimotility agent", "Attempt endoscopic balloon dilation"],
            "Toxic megacolon with deterioration or failure of intensive medical therapy requires urgent surgery. Subtotal colectomy avoids further delay and perforation.",
            "Escalate promptly to colectomy when toxic megacolon worsens despite intensive medical therapy.",
            "Colonoscopy and bowel preparation increase perforation risk in a severely dilated colon.",
            "abdominal distention worsens", "he develops increasing tenderness and shock", "there is no clinical improvement",
            "Shock is an indication to continue indefinite medical therapy", "Full colonoscopy safely decompresses toxic megacolon",
            "Ulcerative Colitis in Adults", "American College of Gastroenterology", "https://gi.org/guideline/ulcerative-colitis-in-adults/", "Surgical indications and urgent colectomy for toxic megacolon."),

        new("strangulated-small-bowel-obstruction-surgery", "Gastrointestinal System", "Surgery", "Gastrointestinal System", "small bowel obstruction",
            "A 61-year-old woman with prior abdominal surgery has vomiting and distention. CT shows a closed-loop small-bowel obstruction with mesenteric edema and reduced bowel-wall enhancement. Pain has become continuous, localized guarding is present, and nasogastric decompression has begun.",
            "Which is the most appropriate next step?",
            ["Emergency operative exploration", "Continue nonoperative observation for 72 hours", "Administer an oral laxative", "Perform colonoscopy", "Discharge after antiemetic therapy"],
            "Closed-loop obstruction with reduced enhancement, continuous pain, and guarding suggests strangulation and ischemia. Emergency exploration is required rather than a prolonged nonoperative trial.",
            "Operate urgently when small-bowel obstruction has signs of strangulation or ischemia.",
            "Nonoperative management is reserved for patients without peritonitis, strangulation, or ischemic imaging findings.",
            "a closed-loop small-bowel obstruction", "reduced bowel-wall enhancement", "localized guarding is present",
            "Every adhesive obstruction warrants a prolonged observation trial", "Nasogastric decompression reverses infarcted bowel",
            "Bologna Guidelines for Adhesive Small Bowel Obstruction", "World Society of Emergency Surgery", "https://wjes.biomedcentral.com/articles/10.1186/s13017-018-0185-2", "Emergency surgery for obstruction with strangulation or bowel ischemia."),

        new("basilar-artery-occlusion-thrombectomy", "Nervous System", "Neurology", "Nervous System & Special Senses", "basilar artery occlusion",
            "A 64-year-old man develops sudden dysarthria, quadriparesis, and declining consciousness. CT angiography shows proximal basilar artery occlusion with salvageable posterior-circulation tissue. He was last known well 8 hours ago, there is no intracranial hemorrhage, and the thrombectomy team is available.",
            "Which treatment is most appropriate?",
            ["Urgent endovascular thrombectomy", "Aspirin alone and routine ward admission", "Delay treatment for repeat imaging tomorrow", "Carotid endarterectomy", "Lumbar puncture"],
            "Disabling basilar artery occlusion with favorable imaging can benefit from endovascular thrombectomy within an extended treatment window. Rapid reperfusion evaluation is essential.",
            "Evaluate eligible patients with acute basilar artery occlusion urgently for endovascular thrombectomy.",
            "Posterior-circulation large-vessel occlusion can cause catastrophic deterioration despite initially limited findings.",
            "proximal basilar artery occlusion", "salvageable posterior-circulation tissue", "there is no intracranial hemorrhage",
            "An extended time window automatically excludes thrombectomy", "Carotid surgery treats basilar occlusion",
            "ESO-ESMINT Guideline on Acute Management of Basilar Artery Occlusion", "European Stroke Organisation", "https://journals.sagepub.com/doi/10.1177/23969873241249980", "Selection of patients with basilar artery occlusion for endovascular treatment."),

        new("cerebral-venous-thrombosis-anticoagulation", "Nervous System", "Neurology", "Nervous System & Special Senses", "cerebral venous thrombosis",
            "A 30-year-old woman 2 weeks postpartum has progressive headache, focal seizure, and left arm weakness. Venography confirms superior sagittal sinus thrombosis with a small hemorrhagic venous infarct. Platelets are normal, there is no aneurysm, and blood pressure is controlled.",
            "Which treatment is most appropriate?",
            ["Therapeutic anticoagulation", "Withhold anticoagulation because any intracranial blood is present", "Aspirin only", "Immediate carotid endarterectomy", "Glucocorticoids alone", "Treat the seizure without addressing the thrombosis"],
            "Cerebral venous thrombosis is treated with therapeutic heparin even when a small hemorrhagic venous infarct is present, because anticoagulation prevents thrombus propagation and improves venous drainage.",
            "Anticoagulate cerebral venous thrombosis despite hemorrhagic venous infarction unless a specific contraindication exists.",
            "Hemorrhage caused by venous congestion is not managed like primary hypertensive intracerebral hemorrhage.",
            "superior sagittal sinus thrombosis", "a small hemorrhagic venous infarct", "platelets are normal",
            "Any intracranial hemorrhage absolutely prohibits anticoagulation", "Antiplatelet therapy is equivalent to therapeutic anticoagulation",
            "Diagnosis and Management of Cerebral Venous Thrombosis", "American Heart Association", "https://www.ahajournals.org/doi/10.1161/STR.0000000000000456", "Anticoagulation for cerebral venous thrombosis including hemorrhagic venous infarction."),

        new("wernicke-thiamine-before-glucose", "Nervous System", "Medicine", "Nervous System & Special Senses", "Wernicke encephalopathy",
            "A 52-year-old man with severe alcohol use disorder is confused and unable to walk. Examination shows gaze-evoked nystagmus and truncal ataxia. He is malnourished, intravenous dextrose is being prepared, and no focal motor deficit is present.",
            "Which treatment should be administered immediately?",
            ["Parenteral thiamine before or with glucose", "Oral folate alone", "Haloperidol as sole treatment", "Wait for thiamine-level confirmation", "Dextrose alone"],
            "Confusion, ocular findings, and ataxia in a malnourished patient indicate Wernicke encephalopathy. High-dose parenteral thiamine should be given promptly before or with carbohydrate.",
            "Treat suspected Wernicke encephalopathy immediately with parenteral thiamine.",
            "A normal or pending serum thiamine measurement should not delay treatment.",
            "gaze-evoked nystagmus", "truncal ataxia", "he is malnourished",
            "Laboratory confirmation must precede thiamine", "Glucose alone corrects thiamine-dependent metabolism",
            "Alcohol-Use Disorders: Diagnosis and Management of Physical Complications", "National Institute for Health and Care Excellence", "https://www.nice.org.uk/guidance/cg100", "Immediate parenteral thiamine for suspected Wernicke encephalopathy."),

        new("catatonia-lorazepam-challenge", "Behavioral Health", "Psychiatry", "Behavioral Health & Social Sciences: Communication, Ethics, Patient Safety", "catatonia",
            "A 33-year-old woman with bipolar disorder becomes mute and motionless. She maintains imposed postures, resists repositioning, and intermittently echoes the examiner's words. Vital signs are stable, neurologic imaging is unrevealing, and there is no lead-pipe rigidity.",
            "Which is the most appropriate initial treatment?",
            ["Lorazepam challenge and scheduled benzodiazepine treatment", "High-potency antipsychotic escalation", "Physical restraints as definitive therapy", "Dopamine agonist for Parkinson disease", "Discharge without treatment", "Supportive observation until spontaneous movement returns"],
            "Mutism, posturing, negativism, and echolalia indicate catatonia. A lorazepam challenge is both diagnostic and therapeutic; electroconvulsive therapy is used for refractory or malignant cases.",
            "Use benzodiazepines first for catatonia and escalate promptly to electroconvulsive therapy when needed.",
            "Antipsychotics can worsen catatonia and increase malignant-catatonia risk before the syndrome is controlled.",
            "she maintains imposed postures", "intermittently echoes the examiner's words", "vital signs are stable",
            "High-potency antipsychotics are the diagnostic test for catatonia", "Immobility should be managed only with restraint",
            "Evidence-Based Consensus Guidelines for the Management of Catatonia", "British Association for Psychopharmacology", "https://journals.sagepub.com/doi/10.1177/02698811231158232", "Lorazepam challenge, benzodiazepine treatment, and ECT for catatonia."),

        new("lithium-toxicity-hemodialysis", "Behavioral Health", "Psychiatry", "Behavioral Health & Social Sciences: Communication, Ethics, Patient Safety", "lithium toxicity",
            "A 67-year-old man taking lithium develops coarse tremor, ataxia, confusion, and repeated seizures after gastroenteritis and acute kidney injury. Lithium dosing has stopped, isotonic fluid is running, neurologic toxicity remains severe, and kidney clearance is impaired.",
            "Which additional treatment is most appropriate?",
            ["Urgent hemodialysis", "Activated charcoal", "Restart lithium at a lower dose", "Urinary alkalinization", "Flumazenil", "Whole-bowel irrigation as definitive therapy"],
            "Severe neurologic lithium toxicity with seizures and impaired kidney clearance is an indication for extracorporeal removal because lithium is small, minimally protein bound, and dialyzable.",
            "Use hemodialysis for severe lithium poisoning, especially with seizures, coma, or impaired elimination.",
            "Activated charcoal does not bind lithium effectively.",
            "repeated seizures", "acute kidney injury", "neurologic toxicity remains severe",
            "Activated charcoal reliably removes lithium", "Stopping lithium alone is adequate despite seizures",
            "Extracorporeal Treatment for Lithium Poisoning", "EXTRIP Workgroup", "https://pmc.ncbi.nlm.nih.gov/articles/PMC4422246/", "Hemodialysis indications in severe lithium poisoning."),

        new("neuroleptic-malignant-syndrome-stop-agent", "Behavioral Health", "Psychiatry", "Behavioral Health & Social Sciences: Communication, Ethics, Patient Safety", "neuroleptic malignant syndrome",
            "A 40-year-old man develops generalized lead-pipe rigidity, autonomic instability, and altered consciousness after a rapid haloperidol dose increase. Creatine kinase is markedly elevated. Haloperidol is still ordered, infection evaluation is unrevealing, and clonus is absent.",
            "Which intervention is most important immediately?",
            ["Stop the dopamine antagonist and begin intensive supportive care", "Continue haloperidol to treat agitation", "Administer an SSRI", "Give succinylcholine", "Discharge with oral hydration"],
            "Lead-pipe rigidity, dysautonomia, altered mental status, and muscle injury after dopamine blockade indicate neuroleptic malignant syndrome. The offending drug must be stopped immediately and aggressive supportive care begun.",
            "Immediately discontinue dopamine antagonists and provide intensive supportive care for neuroleptic malignant syndrome.",
            "Dantrolene or bromocriptine may be considered in severe cases, but drug withdrawal and supportive care cannot wait.",
            "generalized lead-pipe rigidity", "clonus is absent", "creatine kinase is markedly elevated",
            "Continuing the dopamine blocker reverses rigidity", "An SSRI treats dopamine-blockade toxicity",
            "Evidence-Based Consensus Guidelines for the Management of Catatonia", "British Association for Psychopharmacology", "https://pmc.ncbi.nlm.nih.gov/articles/PMC10101189/", "Recognition and immediate withdrawal and supportive management of neuroleptic malignant syndrome."),

        new("capacity-task-specific-assessment", "Professionalism and Ethics", "Ethics", "Behavioral Health & Social Sciences: Communication, Ethics, Patient Safety", "decision-making capacity",
            "A hospitalized 79-year-old man with mild dementia refuses amputation for an ischemic infected foot. He clearly explains that surgery could prevent death, describes the likely consequence of refusal, compares alternatives consistently, and communicates a stable preference. His daughter demands that the physician override him, he is not delirious, and no court has appointed a guardian.",
            "Which is the most appropriate response?",
            ["Honor the refusal after confirming and documenting decision-making capacity", "Assume dementia eliminates capacity", "Let the daughter decide because she disagrees", "Seek a court order solely because the choice is risky", "Sedate the patient and operate"],
            "Capacity is decision-specific and requires understanding, appreciation, reasoning, and communication. This patient demonstrates all four abilities despite making a high-risk choice.",
            "Respect a capable patient's informed refusal even when clinicians or family strongly disagree.",
            "Diagnosis of dementia does not automatically establish incapacity.",
            "he clearly explains that surgery could prevent death", "he is not delirious", "communicates a stable preference",
            "A risky choice proves incapacity", "Family preference overrides a capable adult",
            "Decisions for Adult Patients Who Lack Capacity", "American Medical Association", "https://code-medical-ethics.ama-assn.org/ethics-opinions/decisions-adult-patients-who-lack-capacity", "Assessment of capacity and respect for decisions of capable adults."),

        new("wrong-site-surgery-timeout", "Social Sciences and Patient Safety", "Patient Safety", "Behavioral Health & Social Sciences: Communication, Ethics, Patient Safety", "surgical safety",
            "A patient is in the operating room for left knee arthroscopy. The consent says left knee, but the electronic schedule says right knee. The surgeon has scrubbed, anesthesia has begun, and an old right-knee radiograph is displayed.",
            "Which is the most appropriate action?",
            ["Stop and resolve the discrepancy during the procedural time-out", "Proceed using the electronic schedule", "Let the most senior clinician choose a side", "Operate on both knees", "Document the discrepancy after surgery", "Ask anesthesia to choose based on room setup", "Cover the conflicting radiograph and proceed"],
            "Conflicting procedure information requires an immediate stop before incision. The team must perform the universal-protocol verification and resolve the site using reliable source documents and patient confirmation when possible.",
            "Stop the procedure whenever patient, site, or procedure information conflicts; resolve it before incision.",
            "Hierarchy must not suppress any team member's safety concern.",
            "the consent says left knee", "the electronic schedule says right knee", "an old right-knee radiograph is displayed",
            "The schedule always overrides signed consent", "A discrepancy can be documented after incision",
            "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery", "The Joint Commission", "https://www.jointcommission.org/standards/universal-protocol/", "Preprocedure verification, site marking, and time-out requirements."),

        new("asplenia-vaccination-prevention", "Preventive Medicine & Health Maintenance", "Preventive Medicine", "Preventive Medicine & Health Maintenance", "asplenia vaccination",
            "A 42-year-old woman is scheduled for elective splenectomy. Her routine childhood vaccines are complete, but she has not received vaccines specifically recommended for asplenia. Surgery is planned in 3 weeks, she is not immunosuppressed, and she has no vaccine allergy.",
            "Which preventive strategy is most appropriate?",
            ["Administer indicated pneumococcal, meningococcal, and Haemophilus influenzae type b vaccines before surgery", "Give no additional vaccines because childhood vaccination is complete", "Wait until overwhelming sepsis occurs", "Administer live oral polio vaccine", "Use antibiotics instead of all vaccines"],
            "Anatomic asplenia increases risk from encapsulated organisms. Indicated pneumococcal, meningococcal, and Hib vaccines should be given before elective splenectomy when feasible.",
            "Vaccinate patients with planned asplenia against pneumococcus, meningococcus, and Hib before surgery when possible.",
            "Routine childhood vaccination may not include the complete risk-based adult schedules.",
            "scheduled for elective splenectomy", "surgery is planned in 3 weeks", "she has no vaccine allergy",
            "Childhood vaccination eliminates all asplenia recommendations", "Vaccination should wait until after invasive infection",
            "Adult Immunization Schedule by Medical Condition", "Centers for Disease Control and Prevention", "https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-medical-condition.html", "Risk-based immunization recommendations for anatomic or functional asplenia."),

        new("quality-improvement-pdsa", "Social Sciences and Patient Safety", "Patient Safety", "Behavioral Health & Social Sciences: Communication, Ethics, Patient Safety", "quality improvement",
            "A clinic wants to reduce missed follow-up of abnormal test results. The team maps the current process and proposes a reminder assigned to one nurse. Before changing the whole network, it tests the reminder for one physician during one week, measures completion, and plans modification based on results.",
            "Which quality-improvement method is being used?",
            ["Plan-Do-Study-Act cycle", "Case-control study", "Root cause analysis after a sentinel event", "Randomized phase 3 drug trial", "Failure concealment"],
            "A small, time-limited test of change followed by measurement and adaptation is a Plan-Do-Study-Act cycle.",
            "Use iterative small tests of change and measurement in Plan-Do-Study-Act improvement.",
            "Quality improvement changes are refined through repeated cycles rather than deployed once without feedback.",
            "tests the reminder for one physician", "during one week", "plans modification based on results",
            "PDSA requires immediate systemwide implementation", "Measurement is unnecessary in improvement work",
            "Plan-Do-Study-Act Worksheet", "Institute for Healthcare Improvement", "https://www.ihi.org/resources/tools/plan-do-study-act-pdsa-worksheet", "Use of iterative PDSA cycles for testing healthcare process changes.")
    ];
}