359 lines
54 KiB
C#
359 lines
54 KiB
C#
internal static class SeedCatalog
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{
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private static Seed Q(string slug, string system, string discipline, string topic, string stem, string leadIn, string[] answers, string rationale, string takeaway, string key, string context, string neutral, string reference, string task = "Behavioral Health & Social Sciences: Communication, Ethics, Patient Safety")
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=> new(slug, system, discipline, task, topic, stem, leadIn, answers, rationale, takeaway, key, context, neutral, reference);
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internal static readonly Seed[] All =
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[
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Q("postpartum-psychosis-emergency", "Behavioral Health", "Psychiatry", "postpartum psychosis",
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"A 29-year-old woman 8 days after delivery has slept 2 hours in 4 days. She says her infant is possessed and reports a command to drown him. Her partner has moved the infant to another room. She is euphoric, disorganized, and refuses outpatient care.",
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"Which is the most appropriate next step?",
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["Emergency psychiatric hospitalization with protection of the infant", "Routine follow-up in 6 weeks", "Reassurance that postpartum blues will resolve", "Psychotherapy alone at home", "Allow unsupervised infant care to preserve bonding"],
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"Delusions, mania, severe insomnia, and commands to harm an infant indicate postpartum psychosis with immediate danger. Inpatient treatment and separation from the infant until safe are required.",
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"Postpartum psychosis is a psychiatric emergency requiring hospitalization and immediate protection of parent and infant.", "reports a command to drown him", "8 days after delivery", "her partner has moved the infant to another room", "APA"),
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Q("catatonia-lorazepam-challenge", "Behavioral Health", "Psychiatry", "catatonia",
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"A 43-year-old man with bipolar disorder becomes mute and immobile. He maintains imposed postures, resists repositioning, and repeats the examiner's words. Temperature and autonomic findings are normal. Head CT and metabolic testing are unrevealing.",
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"Which intervention is most appropriate now?",
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["Administer a lorazepam challenge", "Begin high-potency antipsychotic monotherapy", "Use physical restraints as definitive treatment", "Discharge for outpatient psychotherapy", "Wait for fever before treating"],
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"Mutism, posturing, negativism, and echolalia support catatonia. A benzodiazepine challenge is both diagnostically informative and first-line treatment; electroconvulsive therapy is used when severe or refractory.",
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"Recognize catatonia promptly and treat first with benzodiazepines while addressing the cause.", "maintains imposed postures", "temperature and autonomic findings are normal", "head CT and metabolic testing are unrevealing", "APA"),
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Q("delirium-hypoactive-medication-review", "Behavioral Health", "Geriatrics", "hypoactive delirium",
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"An 82-year-old hospitalized woman becomes withdrawn and inattentive after surgery. Her alertness fluctuates during the interview. Diphenhydramine and oxybutynin were added yesterday. She has no focal deficit and was cognitively independent before admission.",
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"Which is the best initial management?",
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["Stop deliriogenic medications and institute multicomponent supportive care", "Diagnose major depression and discharge", "Start a benzodiazepine nightly", "Apply restraints continuously", "Begin a cholinesterase inhibitor for dementia"],
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"Acute fluctuating inattention is hypoactive delirium. Removing anticholinergic contributors and using orientation, mobilization, sleep, hydration, hearing, and vision support treats causes and reduces harm.",
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"Hypoactive delirium is often missed; identify precipitants and use nonpharmacologic supportive measures.", "alertness fluctuates", "diphenhydramine and oxybutynin were added yesterday", "no focal deficit", "APA"),
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Q("alcohol-withdrawal-delirium-benzodiazepines", "Behavioral Health", "Medicine", "alcohol withdrawal",
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"A 51-year-old man hospitalized for pancreatitis becomes tremulous and agitated 72 hours after his last drink. He sees insects on the wall, pulse is 126/min, blood pressure is 178/102 mm Hg, and temperature is 38.1 C. Glucose and oxygenation are normal.",
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"Which treatment should be prioritized?",
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["Symptom-triggered intravenous benzodiazepines with close monitoring", "Haloperidol alone", "Propranolol alone", "Disulfiram immediately", "Physical restraints without medication"],
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"The timing, autonomic hyperactivity, agitation, and visual hallucinations indicate severe alcohol withdrawal. Benzodiazepines prevent seizures and progression; adjuncts do not replace them.",
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"Treat severe alcohol withdrawal with adequately dosed benzodiazepines and supportive monitoring.", "72 hours after his last drink", "sees insects on the wall", "glucose and oxygenation are normal", "SAMHSA"),
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Q("serotonin-syndrome-linezolid", "Behavioral Health", "Medicine", "serotonin syndrome",
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"A 46-year-old woman taking fluoxetine receives linezolid. Thirty-six hours later she has agitation, diaphoresis, diarrhea, inducible ankle clonus, ocular clonus, and hyperreflexia greater in the legs. Temperature is 40.2 C and muscle tone is increased.",
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"Which immediate management is most appropriate?",
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["Stop serotonergic agents, provide supportive care and benzodiazepines, and consider cyproheptadine", "Restart fluoxetine to avoid withdrawal", "Continue linezolid and give dantrolene", "Perform hemodialysis to remove both drugs", "Give bromocriptine and observe"],
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"Clonus and hyperreflexia after serotonergic drug interaction establish serotonin syndrome. Remove serotonergic drugs, cool and sedate supportively, and use cyproheptadine for persistent moderate-to-severe toxicity.",
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"Clonus distinguishes serotonin toxicity; stop causative agents and rapidly control hyperthermia and agitation.", "inducible ankle clonus", "receives linezolid", "temperature is 40.2 C", "APA"),
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Q("anorexia-bradycardia-inpatient", "Behavioral Health", "Psychiatry", "eating disorder instability",
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"A 19-year-old woman with restrictive eating has a body mass index of 14.2 kg/m2. Supine pulse is 42/min, blood pressure is 84/50 mm Hg, potassium is 3.0 mEq/L, and she becomes presyncopal on standing. She requests another outpatient nutrition visit.",
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"Which disposition is most appropriate?",
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["Medical hospitalization with monitored nutritional rehabilitation", "Weekly outpatient weighing only", "Begin a stimulant for fatigue", "Prescribe exercise to restore bone mass", "Delay care until amenorrhea lasts one year"],
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"Severe malnutrition with bradycardia, hypotension, orthostasis, and hypokalemia requires medical stabilization and monitored refeeding because arrhythmia and refeeding complications are imminent.",
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"Physiologic instability in an eating disorder mandates medical hospitalization regardless of patient reassurance.", "pulse is 42/min", "body mass index of 14.2 kg/m2", "she requests another outpatient nutrition visit", "APA"),
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Q("capacity-treatment-refusal", "Professionalism and Ethics", "Ethics", "decision-making capacity",
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"A man with schizophrenia and a gangrenous foot refuses amputation. He accurately explains that without surgery he may die, describes the operation and alternatives, consistently values avoiding dependence over longevity, and is not responding to internal stimuli. His family demands surgery.",
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"Which is the most appropriate action?",
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["Honor the refusal after documenting decision-making capacity", "Obtain family consent and operate", "Assume schizophrenia eliminates capacity", "Seek an emergency court order solely because death is possible", "Sedate him and perform surgery"],
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"Capacity is decision-specific and requires understanding, appreciation, reasoning, and communication of a stable choice. Psychiatric diagnosis alone does not negate it, and a capacitated adult may refuse life-saving care.",
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"Respect a capacitated patient's informed refusal even when clinicians or family strongly disagree.", "accurately explains that without surgery he may die", "has schizophrenia", "his family demands surgery", "AMA"),
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Q("emergency-unrepresented-consent", "Professionalism and Ethics", "Ethics", "emergency consent",
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"An unconscious unidentified patient has a ruptured abdominal aortic aneurysm and will die without immediate surgery. No advance directive or surrogate can be located despite rapid efforts. Delaying for a court order would make repair futile.",
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"What should the physician do?",
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["Proceed with emergency surgery under presumed consent", "Wait for a court-appointed guardian", "Provide comfort care because written consent is absent", "Ask hospital security to consent", "Postpone until identity is confirmed"],
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"Emergency treatment may proceed when delay threatens life, the patient lacks capacity, and no surrogate or directive is available. Care should reflect the patient's presumed interests.",
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"Use presumed consent for immediately necessary emergency care when no authorized decision-maker is available.", "will die without immediate surgery", "no advance directive or surrogate", "patient is unidentified", "AMA"),
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Q("minor-confidential-sti-care", "Professionalism and Ethics", "Pediatrics", "adolescent confidentiality",
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"A 16-year-old requests testing for gonorrhea after unprotected intercourse and asks that her parent not be told. She denies coercion, abuse, self-harm, and danger at home. She understands testing and treatment. Local law permits minors to consent to STI care.",
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"Which response is most appropriate?",
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["Provide confidential STI evaluation while encouraging supportive adult involvement", "Refuse testing without parental permission", "Call the parent before obtaining specimens", "Notify the school", "Report consensual activity as abuse solely because she is a minor"],
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"Where law permits, adolescents may consent confidentially to STI services. Confidentiality improves access; clinicians should explain its limits and encourage, but not require, safe adult support.",
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"Protect legally authorized adolescent confidentiality unless a safety or mandatory-reporting exception applies.", "local law permits minors to consent to STI care", "denies coercion", "asks that her parent not be told", "CDC-STI"),
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Q("impaired-colleague-reporting", "Professionalism and Ethics", "Ethics", "impaired physician",
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"A resident smells alcohol on a surgeon before an emergency case. The surgeon has slurred speech and nearly falls while scrubbing. The department chair is not answering, and the surgeon orders the resident to remain silent.",
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"What is the resident's immediate obligation?",
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["Prevent the surgeon from operating and activate the institutional safety chain", "Obey because the surgeon is senior", "Wait to see whether an error occurs", "Post anonymously on social media", "Confront the surgeon after the case only"],
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"Observable impairment creates an immediate patient threat. The resident must remove the clinician from care through available supervisory or safety channels and ensure coverage, with subsequent formal reporting.",
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"Patient safety overrides hierarchy when a clinician appears impaired during care.", "slurred speech", "before an emergency case", "department chair is not answering", "AMA"),
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Q("error-disclosure", "Professionalism and Ethics", "Ethics", "medical error disclosure",
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"A physician accidentally orders ten times the intended insulin dose. The error causes symptomatic hypoglycemia that is promptly reversed without lasting injury. The patient asks why emergency dextrose was required. Risk management suggests saying only that glucose fell.",
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"Which response is most appropriate?",
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["Disclose the dosing error, its effects, treatment, and prevention plan", "Withhold the error because no permanent harm occurred", "Blame the nurse who administered the order", "Alter the record to show the intended dose", "Wait until the patient obtains the chart"],
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"Patients should receive timely, factual disclosure of harmful errors, including consequences, corrective care, and prevention steps. Lack of permanent injury does not remove this duty.",
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"Disclose clinically significant errors honestly and explain mitigation and prevention.", "ten times the intended insulin dose", "without lasting injury", "risk management suggests saying only that glucose fell", "AMA"),
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Q("confidentiality-driving-risk", "Professionalism and Ethics", "Neurology", "confidentiality exception",
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"A commercial bus driver with uncontrolled focal impaired-awareness seizures continues driving and refuses to notify the licensing authority. He had two episodes while driving this month. The physician has reviewed applicable state law, which mandates clinician reporting of unsafe drivers.",
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"Which action is appropriate?",
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["Report the minimum necessary information to the designated authority", "Maintain absolute confidentiality", "Notify the driver's employer and all passengers", "Post a warning publicly", "Prescribe a placebo and take no other action"],
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"Confidentiality has narrow exceptions when law mandates reporting to prevent serious harm. Disclosure should go only to the proper authority and be limited to necessary information.",
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"When reporting is legally required to prevent serious harm, disclose only what is necessary through the proper channel.", "state law mandates clinician reporting", "two episodes while driving this month", "commercial bus driver", "AMA"),
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Q("lung-cancer-screening-ldct", "Preventive Medicine & Health Maintenance", "Medicine", "lung cancer screening",
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"A 61-year-old man has a 28-pack-year smoking history and quit 6 years ago. He has no cough, weight loss, or hemoptysis and is healthy enough for curative lung surgery. Chest examination is normal.",
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"Which screening strategy is appropriate?",
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["Annual low-dose chest CT", "Annual chest radiography", "Sputum cytology every 6 months", "No screening until symptoms develop", "One-time contrast chest CT only"],
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"An asymptomatic adult age 50-80 with at least 20 pack-years who currently smokes or quit within 15 years should be offered annual low-dose CT after shared decision-making.",
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"Use annual low-dose CT, not chest radiography, for eligible high-risk adults.", "28-pack-year smoking history", "quit 6 years ago", "no cough", "USPSTF", "Preventive Medicine & Health Maintenance"),
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Q("aaa-screening", "Preventive Medicine & Health Maintenance", "Medicine", "abdominal aortic aneurysm screening",
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"A healthy 68-year-old man smoked one pack daily for 25 years before quitting. He has never undergone abdominal imaging. Blood pressure is controlled and abdominal examination is normal.",
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"Which preventive service should be offered?",
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["One-time abdominal ultrasonography", "Annual abdominal CT", "No screening because he quit smoking", "Carotid ultrasonography", "Serial abdominal radiographs"],
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"Men age 65-75 who have ever smoked benefit from one-time ultrasound screening for abdominal aortic aneurysm.",
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"Offer one-time abdominal ultrasound to men age 65-75 who have ever smoked.", "68-year-old man", "smoked one pack daily for 25 years", "abdominal examination is normal", "USPSTF", "Preventive Medicine & Health Maintenance"),
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Q("osteoporosis-screening-dxa", "Preventive Medicine & Health Maintenance", "Medicine", "osteoporosis screening",
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"A 66-year-old woman presents for preventive care. She has never fractured a bone, takes no glucocorticoids, and walks daily. Menopause occurred at age 51 and physical examination is normal.",
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"Which screening is recommended now?",
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["Dual-energy x-ray absorptiometry", "Plain radiographs of the spine", "Serum calcium alone", "No screening without fracture", "Bone biopsy"],
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"Routine osteoporosis screening with DXA is recommended for women age 65 years or older, independent of additional risk factors.",
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"Screen women age 65 or older for osteoporosis with DXA.", "66-year-old woman", "has never fractured a bone", "walks daily", "USPSTF", "Preventive Medicine & Health Maintenance"),
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Q("colorectal-screening-positive-fit", "Preventive Medicine & Health Maintenance", "Medicine", "colorectal cancer screening",
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"A 58-year-old asymptomatic woman completes an annual fecal immunochemical test, which is positive. Hemoglobin is normal, she has no family history of colorectal cancer, and her last colonoscopy was 12 years ago.",
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"Which is the most appropriate next step?",
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["Diagnostic colonoscopy", "Repeat the fecal test immediately", "CT abdomen without bowel preparation", "Reassure because hemoglobin is normal", "Begin aspirin and repeat testing next year"],
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"A positive stool-based colorectal screening test requires colonoscopy to identify and remove the bleeding lesion; repeating the stool test does not complete screening.",
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"Follow every positive stool-based colorectal cancer screen with timely colonoscopy.", "fecal immunochemical test, which is positive", "hemoglobin is normal", "last colonoscopy was 12 years ago", "USPSTF", "Preventive Medicine & Health Maintenance"),
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Q("cervical-screening-immunized", "Preventive Medicine & Health Maintenance", "Gynecology", "cervical cancer screening",
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"A 32-year-old woman received a complete HPV vaccine series at age 13. Cervical cytology 3 years ago was negative. She has no immunocompromise, in-utero diethylstilbestrol exposure, or prior high-grade lesion.",
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"Which statement best guides current screening?",
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["Continue age-appropriate cervical screening despite vaccination", "Stop screening because vaccination eliminates risk", "Perform annual endometrial biopsy", "Screen only if symptoms develop", "Begin ovarian cancer screening instead"],
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"HPV vaccination substantially reduces risk but does not eliminate all oncogenic HPV exposure or replace routine cervical screening schedules.",
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"HPV-vaccinated patients still need routine age-appropriate cervical cancer screening.", "complete HPV vaccine series", "cytology 3 years ago was negative", "no immunocompromise", "USPSTF", "Preventive Medicine & Health Maintenance"),
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Q("falls-prevention-exercise", "Preventive Medicine & Health Maintenance", "Geriatrics", "fall prevention",
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"A 76-year-old woman living independently fell twice this year without injury. Vision and neurologic examination are normal. She takes no sedatives, but gait testing shows impaired balance and reduced leg strength.",
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"Which intervention has the best evidence for prevention?",
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["A structured exercise program emphasizing balance and strength", "Routine hip radiographs", "Prophylactic bed rest", "Daily benzodiazepine", "A wheelchair for all mobility"],
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"Exercise interventions that target balance, gait, and strength reduce falls in community-dwelling older adults at increased risk.",
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"Use structured balance and strength exercise for older adults at increased fall risk.", "impaired balance and reduced leg strength", "fell twice this year", "vision and neurologic examination are normal", "USPSTF", "Preventive Medicine & Health Maintenance"),
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Q("migraine-aura-contraception", "Female Reproductive System and Breast", "Gynecology", "contraception migraine aura",
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"A 27-year-old woman with migraine with visual aura requests contraception. She does not smoke and has normal blood pressure. She prefers a highly effective reversible method and has no contraindication to an intrauterine device.",
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"Which option is most appropriate?",
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["Levonorgestrel intrauterine device", "Combined estrogen-progestin pill", "Combined hormonal patch", "Combined vaginal ring", "High-dose estrogen injection"],
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"Migraine with aura makes combined hormonal contraception an unacceptable stroke risk. A levonorgestrel IUD is highly effective and does not carry the estrogen-related contraindication.",
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"Avoid estrogen-containing contraception in migraine with aura; offer an effective nonestrogen method.", "migraine with visual aura", "does not smoke", "normal blood pressure", "CDC-MEC", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("postpartum-endometritis", "Female Reproductive System and Breast", "Obstetrics", "postpartum endometritis",
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"Two days after an unplanned cesarean delivery, a 31-year-old woman has fever, uterine fundal tenderness, and foul-smelling lochia. The incision is clean, urinalysis is normal, and there is no calf tenderness.",
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"Which treatment is most appropriate?",
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["Intravenous clindamycin plus gentamicin", "Oral fluconazole", "Incision drainage despite a clean wound", "Anticoagulation alone", "Observation without antibiotics"],
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"Postcesarean fever with uterine tenderness and malodorous lochia indicates polymicrobial postpartum endometritis. Broad intravenous anaerobic and gram-negative coverage is required.",
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"Treat postpartum endometritis with broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms.", "uterine fundal tenderness", "foul-smelling lochia", "incision is clean", "ACOG", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("ectopic-pregnancy-methotrexate-failure", "Female Reproductive System and Breast", "Obstetrics", "ectopic pregnancy",
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"A hemodynamically stable woman receives methotrexate for a small unruptured tubal ectopic pregnancy. Her beta-hCG level falls 3% between treatment days 4 and 7. She has mild unchanged pelvic discomfort and no peritoneal signs.",
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"Which is the most appropriate next step?",
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["Administer an additional methotrexate dose or proceed with surgical management", "Declare treatment successful and stop follow-up", "Repeat beta-hCG in one year", "Begin progesterone supplementation", "Perform uterine curettage as definitive tubal treatment"],
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"A decline of less than 15% from days 4 to 7 indicates inadequate response. Additional methotrexate or surgery is needed, with continued surveillance until resolution.",
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"After methotrexate for ectopic pregnancy, a day-4-to-7 hCG decline below 15% requires further treatment.", "falls 3% between treatment days 4 and 7", "hemodynamically stable", "no peritoneal signs", "ACOG", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("preeclampsia-severe-delivery", "Female Reproductive System and Breast", "Obstetrics", "preeclampsia severe features",
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"A woman at 36 weeks has blood pressure of 168/112 mm Hg on repeated measurements, new right upper-quadrant pain, platelets of 82,000/mm3, and elevated aminotransferases. Fetal testing is reassuring.",
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"Which management is most appropriate after stabilization?",
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["Magnesium sulfate, acute blood-pressure treatment, and delivery", "Expectant outpatient management until 40 weeks", "Tocolysis and discharge", "Aspirin as sole treatment", "Repeat laboratory testing in one month"],
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"Severe hypertension, thrombocytopenia, and hepatic symptoms establish preeclampsia with severe features. At 36 weeks, stabilize the mother, prevent seizure, and deliver.",
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"Preeclampsia with severe features at or beyond 34 weeks generally requires maternal stabilization followed by delivery.", "platelets of 82,000/mm3", "36 weeks", "fetal testing is reassuring", "ACOG", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("shoulder-dystocia-mcRoberts", "Female Reproductive System and Breast", "Obstetrics", "shoulder dystocia",
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"During vaginal delivery, the fetal head delivers and retracts against the perineum. Gentle downward traction does not deliver the shoulders. The mother has an epidural, fetal heart rate is 90/min, and an assistant is present.",
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"Which maneuver should be performed first?",
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["McRoberts positioning with suprapubic pressure", "Fundal pressure", "Immediate cesarean delivery", "Forceful traction on the fetal head", "Vacuum extraction of the delivered head"],
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"The turtle sign indicates shoulder dystocia. Initial maneuvers are maternal hip hyperflexion and suprapubic pressure; fundal pressure and forceful traction worsen impaction and injury.",
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"Begin shoulder dystocia management with McRoberts positioning and suprapubic pressure.", "head delivers and retracts", "assistant is present", "mother has an epidural", "ACOG", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("postmenopausal-bleeding-biopsy", "Female Reproductive System and Breast", "Gynecology", "postmenopausal bleeding",
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"A 63-year-old woman with obesity and diabetes reports new painless vaginal bleeding 11 years after menopause. Pelvic examination shows no cervical lesion. She uses no hormone therapy and is hemodynamically stable.",
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"Which evaluation is most appropriate?",
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["Endometrial assessment with transvaginal ultrasonography or biopsy", "Reassurance that bleeding is expected", "Serum CA-125 alone", "Empiric antibiotics", "Repeat examination in one year"],
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"Any postmenopausal bleeding requires prompt evaluation for endometrial cancer. Transvaginal ultrasonography or endometrial sampling is an appropriate initial approach depending on context.",
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"Evaluate postmenopausal bleeding promptly for endometrial neoplasia.", "new painless vaginal bleeding 11 years after menopause", "obesity and diabetes", "no cervical lesion", "ACOG", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("torsion-surgery", "Female Reproductive System and Breast", "Gynecology", "ovarian torsion",
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"A 24-year-old woman develops sudden severe unilateral pelvic pain with vomiting. Ultrasonography shows an enlarged ovary with peripheral follicles; Doppler demonstrates some arterial flow. Pregnancy testing is negative and pain persists despite analgesia.",
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"Which is the most appropriate next step?",
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["Urgent diagnostic laparoscopy with detorsion", "Discharge because arterial flow excludes torsion", "Repeat ultrasonography in 6 months", "Methotrexate", "Endometrial biopsy"],
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"Torsion is a clinical and surgical diagnosis. Preserved Doppler arterial flow does not exclude intermittent or partial torsion; prompt laparoscopy maximizes ovarian salvage.",
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"Do not exclude ovarian torsion because Doppler flow persists; operate urgently when suspicion is high.", "sudden severe unilateral pelvic pain", "some arterial flow", "pregnancy testing is negative", "ACOG", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("pelvic-inflammatory-disease-outpatient", "Female Reproductive System and Breast", "Gynecology", "pelvic inflammatory disease",
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"A 22-year-old woman has bilateral lower abdominal pain, mucopurulent cervical discharge, and cervical motion tenderness. Pregnancy testing is negative. She is afebrile, tolerates oral medication, and has no tubo-ovarian abscess.",
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"Which treatment is most appropriate?",
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["Outpatient ceftriaxone, doxycycline, and metronidazole", "Wait for gonorrhea culture confirmation", "Fluconazole alone", "Immediate hysterectomy", "Azithromycin single dose alone"],
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"Minimum clinical criteria justify empiric PID treatment to prevent infertility. Stable patients can receive recommended broad outpatient coverage for gonorrhea, chlamydia, and anaerobes.",
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"Treat suspected PID empirically when minimum clinical criteria are met; do not wait for microbiologic confirmation.", "cervical motion tenderness", "tolerates oral medication", "pregnancy testing is negative", "CDC-STI", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("sudden-sensorineural-hearing-loss", "Ear, Nose & Throat", "Otolaryngology", "sudden hearing loss",
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"A 47-year-old man awakens with marked hearing loss in the left ear and tinnitus. Otoscopic examination is normal. Weber testing lateralizes to the right and Rinne testing shows air conduction greater than bone conduction bilaterally. Symptoms began 18 hours ago.",
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"Which is the most appropriate next step?",
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["Urgent corticosteroid treatment and audiologic evaluation", "Cerumen irrigation", "Routine follow-up in 3 months", "Oral antibiotics for otitis media", "Reassurance that normal otoscopy excludes urgency"],
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"Tuning-fork findings indicate sudden sensorineural hearing loss, an otologic emergency. Prompt corticosteroid therapy and audiometry improve the chance of recovery.",
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"Treat sudden sensorineural hearing loss urgently; a normal ear canal and tympanic membrane do not make it benign.", "Weber testing lateralizes to the right", "otoscopic examination is normal", "symptoms began 18 hours ago", "AAO-HNS", "Nervous System & Special Senses"),
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Q("peritonsillar-abscess-drainage", "Ear, Nose & Throat", "Emergency Medicine", "peritonsillar abscess",
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"A 20-year-old man has fever, severe unilateral throat pain, drooling, muffled voice, trismus, and deviation of the uvula away from a swollen tonsillar pillar. He has no stridor and can sit upright.",
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"Which management is most appropriate?",
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["Drain the abscess and give antibiotics", "Rapid streptococcal testing alone", "Discharge with an antihistamine", "Immediate tonsil radiation", "Observe without airway assessment"],
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"Trismus, muffled voice, unilateral swelling, and uvular deviation indicate peritonsillar abscess. Treatment requires drainage plus antimicrobial therapy while monitoring the airway.",
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"Peritonsillar abscess requires source control and antibiotics, with airway assessment first.", "deviation of the uvula", "has no stridor", "can sit upright", "AAO-HNS", "Nervous System & Special Senses"),
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Q("epistaxis-posterior", "Ear, Nose & Throat", "Emergency Medicine", "posterior epistaxis",
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"A 74-year-old man taking apixaban has brisk nasal bleeding into the posterior pharynx. Firm compression and topical vasoconstrictor fail. No anterior bleeding point is visible, blood pressure is stable, and large clots continue to enter the throat.",
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"Which is the most appropriate next step?",
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["Posterior nasal packing with monitored otolaryngology management", "Repeated nose blowing", "Discharge with petroleum jelly", "Tilt the head backward and swallow blood", "Elective sinus CT in one month"],
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"Persistent bleeding into the pharynx without an anterior source suggests posterior epistaxis. Posterior packing or procedural control and monitored specialty care are necessary because airway and hemodynamic complications can occur.",
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"Escalate suspected posterior epistaxis to packing or procedural control in a monitored setting.", "large clots continue to enter the throat", "blood pressure is stable", "no anterior bleeding point is visible", "AAO-HNS", "Nervous System & Special Senses"),
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Q("deep-neck-infection-airway", "Ear, Nose & Throat", "Emergency Medicine", "deep neck infection",
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"A 39-year-old man with a mandibular molar infection develops bilateral submandibular swelling, tongue elevation, drooling, and a muffled voice. He is sitting forward and oxygen saturation is 94% on room air. Neck examination shows woody induration.",
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"Which action has highest priority?",
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["Secure the airway with expert assistance before deterioration", "Send him home with oral mouthwash", "Perform blind oral intubation after sedation", "Wait for fluctuance before treatment", "Obtain dental radiographs before airway planning"],
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"Ludwig angina can rapidly obstruct the airway. Early controlled airway management with anesthesia and otolaryngology support precedes antibiotics and surgical source control when needed.",
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"In a deep neck infection with tongue elevation and drooling, secure the airway early under controlled conditions.", "tongue elevation", "oxygen saturation is 94%", "woody induration", "AAO-HNS", "Nervous System & Special Senses"),
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Q("malignant-otitis-externa", "Ear, Nose & Throat", "Medicine", "necrotizing otitis externa",
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"A 71-year-old man with poorly controlled diabetes has severe nocturnal ear pain and purulent drainage despite topical therapy. Granulation tissue is present at the bony-cartilaginous junction of the canal. He is afebrile and the tympanic membrane is intact.",
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"Which management is most appropriate?",
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["Systemic antipseudomonal therapy and urgent specialty evaluation", "Topical anesthetic drops alone", "Routine cerumen removal and discharge", "Oral amoxicillin for 3 days", "Observation because he is afebrile"],
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"Severe refractory otalgia, diabetes, and canal granulation tissue suggest invasive Pseudomonas infection of the skull base. Prolonged systemic antipseudomonal treatment and ENT assessment are required.",
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"Suspect necrotizing otitis externa in a diabetic patient with severe persistent pain and canal granulation tissue.", "granulation tissue", "poorly controlled diabetes", "tympanic membrane is intact", "AAO-HNS", "Nervous System & Special Senses"),
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Q("anaphylaxis-epinephrine", "Immune System", "Emergency Medicine", "anaphylaxis",
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"Minutes after eating a cookie, a 17-year-old develops diffuse urticaria, wheezing, vomiting, and blood pressure of 78/42 mm Hg. The airway is currently patent. Intravenous access has not yet been obtained.",
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"Which medication should be administered first?",
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["Intramuscular epinephrine in the lateral thigh", "Intravenous diphenhydramine", "Nebulized albuterol alone", "Intravenous glucocorticoid", "Subcutaneous epinephrine after IV access"],
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"Multisystem allergic symptoms with hypotension are anaphylaxis. Intramuscular epinephrine is the immediate first-line treatment and should not be delayed for venous access or adjuncts.",
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"Give intramuscular epinephrine immediately for anaphylaxis; antihistamines and steroids are adjuncts.", "blood pressure of 78/42 mm Hg", "airway is currently patent", "intravenous access has not yet been obtained", "AAAAI", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("ace-inhibitor-angioedema-airway", "Immune System", "Emergency Medicine", "angioedema",
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"A 64-year-old man taking lisinopril develops progressive tongue and floor-of-mouth swelling without urticaria. His voice is muffled, he cannot handle secretions, and oxygen saturation remains 97% on room air.",
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"Which action is most important?",
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["Early definitive airway management and discontinuation of lisinopril", "Wait for oxygen desaturation", "Give an oral antihistamine and discharge", "Continue lisinopril after swelling resolves", "Perform skin-prick testing before treatment"],
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"Bradykinin-mediated ACE inhibitor angioedema often lacks urticaria and may progress rapidly. Inability to handle secretions and voice change require early controlled airway protection.",
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"In ACE inhibitor angioedema, airway findings—not oxygen saturation alone—determine the need for early airway control.", "cannot handle secretions", "without urticaria", "oxygen saturation remains 97%", "AAAAI", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("common-variable-immunodeficiency", "Immune System", "Medicine", "primary immunodeficiency",
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"A 28-year-old woman has recurrent bacterial sinusitis and two episodes of pneumonia. IgG and IgA levels are markedly reduced, vaccine antibody responses are poor, and absolute B-cell count is normal. HIV testing is negative.",
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"Which long-term treatment is most appropriate?",
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["Immunoglobulin replacement therapy", "Daily systemic glucocorticoids", "Splenectomy", "Live vaccines monthly", "No treatment because B cells are present"],
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"Low immunoglobulins and impaired specific antibody response with preserved B-cell numbers support common variable immunodeficiency. Immunoglobulin replacement reduces serious bacterial infections.",
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"Treat clinically significant antibody deficiency in common variable immunodeficiency with immunoglobulin replacement.", "vaccine antibody responses are poor", "absolute B-cell count is normal", "HIV testing is negative", "AAAAI", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("hereditary-angioedema", "Immune System", "Medicine", "hereditary angioedema",
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"A 23-year-old man has recurrent nonpruritic swelling of the hands, severe episodic abdominal pain, and a family history of similar attacks. During episodes he has no urticaria. Complement testing shows persistently low C4.",
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"Which treatment is appropriate for an acute laryngeal attack?",
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["C1 esterase inhibitor concentrate", "Diphenhydramine alone", "High-dose aspirin", "Epinephrine as the only definitive therapy", "Oral antibiotics"],
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"Recurrent angioedema without hives, abdominal attacks, family history, and low C4 indicate hereditary C1 inhibitor deficiency. Acute attacks require targeted bradykinin-pathway therapy such as C1 inhibitor concentrate.",
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"Hereditary angioedema is bradykinin-mediated and requires targeted on-demand therapy, especially for laryngeal attacks.", "persistently low C4", "no urticaria", "family history of similar attacks", "AAAAI", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("serum-sickness-like", "Immune System", "Pediatrics", "serum sickness",
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"A 9-year-old boy develops fever, urticarial eruption, arthralgias, and lymphadenopathy 9 days after starting cefaclor. Urinalysis shows mild proteinuria, complement levels are low, and there is no mucosal erosion.",
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"Which is the most appropriate initial management?",
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["Discontinue the triggering drug and provide supportive therapy", "Continue cefaclor to complete the course", "Administer epinephrine for isolated delayed symptoms", "Begin lifelong immunoglobulin replacement", "Perform emergent skin debridement"],
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"The delayed fever, rash, arthralgia, and hypocomplementemia indicate an immune-complex serum sickness reaction. Removing the antigen and supportive therapy are primary; severe cases may need systemic steroids.",
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"For serum sickness, stop the causative exposure and treat symptomatically while assessing organ involvement.", "9 days after starting cefaclor", "complement levels are low", "no mucosal erosion", "AAAAI", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("wrong-patient-near-miss", "Social Sciences and Patient Safety", "Patient Safety", "near miss analysis",
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"A nurse scans a medication and receives a wrong-patient alert before administration. The two patients have the same surname and were placed in adjacent rooms; no drug reaches either patient. Staff routinely bypass a second identifier during busy shifts.",
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"Which response best improves safety?",
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["Report the near miss and analyze system causes including identifier workflow", "Take no action because no injury occurred", "Discipline the nurse without reviewing the process", "Disable barcode alerts", "Move only these two patients and close the review"],
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"Near misses reveal hazards before harm occurs. Reporting and systems analysis can address room assignment, identifier use, alert design, staffing, and workarounds rather than relying on individual blame.",
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"Analyze near misses for latent system defects even when the safety barrier prevents harm.", "wrong-patient alert before administration", "no drug reaches either patient", "routinely bypass a second identifier", "AHRQ"),
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Q("root-cause-analysis", "Social Sciences and Patient Safety", "Patient Safety", "root cause analysis",
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"A patient receives a concentrated electrolyte instead of a flush and has a cardiac arrest. The vials had similar labels, were stored together, and the electronic order did not require pharmacy verification. Multiple staff followed the same usual workflow.",
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"Which corrective action is most likely to prevent recurrence?",
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["Redesign storage, labeling, and verification barriers through a root cause analysis", "Retrain the last nurse only", "Ask staff to be more careful", "Keep the vials together for convenience", "Suppress incident reporting"],
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"The event reflects several latent system hazards. Root cause analysis should produce strong safeguards such as segregation, standardization, forcing functions, and independent verification.",
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"Use systems analysis and strong process controls rather than education or blame alone after a serious safety event.", "vials had similar labels", "stored together", "multiple staff followed the same usual workflow", "AHRQ"),
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Q("central-line-bundle", "Social Sciences and Patient Safety", "Patient Safety", "infection prevention bundle",
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"An ICU has a rising central-line bloodstream infection rate. Audits show inconsistent chlorhexidine skin preparation, unnecessary femoral lines, and no daily review of line necessity. Individual clinicians use different insertion practices.",
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"Which intervention is most effective?",
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["Implement a standardized insertion and maintenance bundle with daily necessity review", "Treat every patient with prophylactic antibiotics", "Replace every line daily", "Publish clinician names without process changes", "Culture all line tips weekly"],
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"Central-line bundles combine hand hygiene, maximal barrier precautions, chlorhexidine, site selection, maintenance, and prompt removal. Standardized reliable execution addresses the observed process defects.",
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"Prevent central-line infection through a consistently applied bundle and removal of unnecessary lines.", "no daily review of line necessity", "inconsistent chlorhexidine skin preparation", "individual clinicians use different insertion practices", "AHRQ"),
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Q("handoff-readback", "Social Sciences and Patient Safety", "Patient Safety", "closed-loop communication",
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"During a chaotic trauma resuscitation, the team leader requests 1 unit of uncrossmatched blood. Two nurses hear different quantities, and neither repeats the order. Similar verbal-order misunderstandings have occurred during prior resuscitations.",
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"Which change most directly addresses this hazard?",
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["Require closed-loop communication with read-back of critical verbal orders", "Ban all speech during resuscitation", "Add a longer incident form", "Ask only senior staff to listen", "Delay all treatment until orders are typed"],
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"Closed-loop communication requires the receiver to repeat the order and the sender to confirm it, catching misheard critical instructions in real time.",
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"Use read-back and confirmation for critical verbal orders in high-risk settings.", "neither repeats the order", "two nurses hear different quantities", "chaotic trauma resuscitation", "AHRQ"),
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Q("control-chart-special-cause", "Social Sciences and Patient Safety", "Quality Improvement", "statistical process control",
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"A clinic plots monthly missed-result rates on a control chart. After a new inbox system, eight consecutive points fall below the previous centerline, although every point remains within the old control limits. Patient volume is unchanged.",
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"How should this pattern be interpreted?",
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["A nonrandom shift suggests special-cause improvement", "No change occurred because limits were not crossed", "The process necessarily became less stable", "The sample must be discarded", "The centerline can never be recalculated"],
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"A sustained run on one side of the centerline is a standard nonrandom signal even without a point beyond control limits. The timing supports a process shift associated with the intervention.",
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"Control charts detect nonrandom runs and shifts, not only points outside control limits.", "eight consecutive points fall below", "within the old control limits", "patient volume is unchanged", "AHRQ"),
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Q("language-interpreter", "Social Sciences and Patient Safety", "Communication", "medical interpretation",
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"A patient with limited English proficiency is considering high-risk surgery. His adult daughter offers to interpret, but she omits discussion of infertility because it is embarrassing. A qualified video interpreter is immediately available.",
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"Which is the best approach?",
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["Use the qualified medical interpreter for informed consent", "Use the daughter because she is family", "Obtain a signature without further discussion", "Cancel surgery permanently", "Ask another patient to interpret"],
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"Meaningful informed consent requires accurate, complete communication. A qualified interpreter reduces omissions and conflicts while family may participate at the patient's request.",
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"Use a qualified medical interpreter for consequential clinical communication and informed consent.", "omits discussion of infertility", "qualified video interpreter is immediately available", "adult daughter offers to interpret", "AHRQ"),
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Q("thyroid-storm-treatment", "Endocrine System", "Medicine", "thyroid storm",
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"A 36-year-old woman with untreated Graves disease has fever of 40 C, agitation, vomiting, atrial fibrillation at 170/min, and heart failure after pneumonia. She is receiving supportive resuscitation and has no contraindication to beta blockade.",
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"Which medication sequence is appropriate?",
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["Beta blocker, thionamide, then iodine after thionamide, plus glucocorticoid", "Iodine before thionamide", "Levothyroxine and aspirin", "Radioactive iodine as immediate monotherapy", "Observation until thyroid tests return"],
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"Thyroid storm requires rapid multimodal therapy. Block adrenergic effects and synthesis first, then give iodine after thionamide to avoid providing substrate for new hormone production; steroids reduce conversion and treat possible adrenal insufficiency.",
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"In thyroid storm, give iodine only after a thionamide, along with beta blockade, steroids, and supportive care.", "fever of 40 C", "untreated Graves disease", "after pneumonia", "ENDO", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("adrenal-crisis", "Endocrine System", "Medicine", "adrenal crisis",
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"A 45-year-old woman with autoimmune adrenal insufficiency presents with vomiting, confusion, blood pressure of 72/40 mm Hg, sodium of 124 mEq/L, potassium of 6.1 mEq/L, and glucose of 48 mg/dL after gastroenteritis.",
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"Which treatment should begin immediately?",
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["Intravenous hydrocortisone and isotonic saline with dextrose", "Wait for cosyntropin testing", "Fluid restriction", "Insulin without glucose", "Oral fludrocortisone alone"],
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"Shock, hypoglycemia, hyponatremia, and hyperkalemia in known adrenal insufficiency indicate adrenal crisis. Stress-dose hydrocortisone and rapid volume and glucose replacement must not await testing.",
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"Treat suspected adrenal crisis immediately with parenteral glucocorticoid and volume resuscitation.", "blood pressure of 72/40 mm Hg", "glucose of 48 mg/dL", "after gastroenteritis", "ENDO", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("pheochromocytoma-alpha-before-beta", "Endocrine System", "Surgery", "pheochromocytoma preparation",
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"A 42-year-old woman has episodic headache, diaphoresis, palpitations, and an adrenal mass with elevated plasma metanephrines. Resection is planned. Blood pressure is 176/104 mm Hg and pulse is 112/min.",
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"Which preoperative strategy is appropriate?",
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["Establish alpha blockade before adding beta blockade", "Begin propranolol before alpha blockade", "Proceed directly to surgery without preparation", "Restrict salt and fluid severely", "Treat with levothyroxine"],
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"Alpha blockade and volume expansion prepare patients for resection. Giving beta blockade first can leave unopposed alpha stimulation and precipitate hypertensive crisis.",
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"For pheochromocytoma, establish adequate alpha blockade before treating residual tachycardia with a beta blocker.", "elevated plasma metanephrines", "blood pressure is 176/104 mm Hg", "resection is planned", "ENDO", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("hypercalcemic-crisis-fluids", "Endocrine System", "Medicine", "severe hypercalcemia",
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"A 69-year-old man with metastatic squamous cell carcinoma has confusion, constipation, polyuria, corrected calcium of 15.8 mg/dL, and creatinine of 2.0 mg/dL. Mucous membranes are dry and lungs are clear.",
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"Which treatment should be initiated first?",
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["Aggressive isotonic saline followed by rapid antiresorptive therapy", "Thiazide diuretic", "Fluid restriction", "Oral calcium supplementation", "Observation until parathyroid hormone returns"],
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"Severe symptomatic hypercalcemia causes volume depletion. Isotonic saline restores perfusion, while calcitonin and an intravenous bisphosphonate or denosumab lower calcium based on context.",
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"Begin treatment of severe symptomatic hypercalcemia with isotonic volume expansion and prompt calcium-lowering therapy.", "corrected calcium of 15.8 mg/dL", "mucous membranes are dry", "lungs are clear", "ENDO", "Immune/Blood & Lymphoreticular/Endocrine/Multisystem"),
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Q("testicular-torsion-exploration", "Male Reproductive System", "Urology", "testicular torsion",
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"A 15-year-old boy has sudden severe left scrotal pain, vomiting, a high-riding horizontal testis, and an absent cremasteric reflex. Symptoms began 3 hours ago. The operating room is available immediately.",
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"Which is the most appropriate next step?",
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["Immediate surgical exploration and bilateral orchiopexy", "Wait for outpatient ultrasonography", "Treat epididymitis with oral antibiotics", "Needle aspiration", "Reassess after 24 hours"],
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"The classic presentation has high pretest probability for torsion. Surgical exploration must not be delayed for imaging, and the contralateral testis is fixed because the anatomic predisposition is usually bilateral.",
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"When testicular torsion is clinically clear, proceed directly to urgent exploration and bilateral fixation.", "absent cremasteric reflex", "symptoms began 3 hours ago", "operating room is available immediately", "AUA", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("priapism-aspiration", "Male Reproductive System", "Urology", "ischemic priapism",
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"A 38-year-old man with sickle cell disease has a painful rigid erection for 6 hours. The corpora cavernosa are hard, the glans is soft, and cavernosal blood gas shows acidosis and hypoxia. Hydration and analgesia have not produced detumescence.",
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"Which is the most appropriate next step?",
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["Corporal aspiration and irrigation with intracavernosal phenylephrine", "Observation until 24 hours", "Oral sildenafil", "Apply a warm compress only", "Elective penile Doppler next month"],
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"Painful low-flow priapism is a compartment syndrome of the penis. Aspiration, irrigation, and intracavernosal sympathomimetic therapy are urgent to prevent necrosis and erectile dysfunction.",
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"Treat ischemic priapism urgently with aspiration and intracavernosal phenylephrine.", "cavernosal blood gas shows acidosis and hypoxia", "sickle cell disease", "hydration and analgesia have not produced detumescence", "AUA", "Renal/Urinary & Male/Female Systems & Pregnancy"),
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Q("sjs-ten-drug-withdrawal", "Skin and Subcutaneous Tissue", "Dermatology", "Stevens-Johnson syndrome",
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"A 35-year-old woman develops fever, painful dusky targetoid lesions, oral erosions, and conjunctivitis 10 days after starting lamotrigine. Epidermal detachment involves 8% of body surface area. Nikolsky sign is present.",
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"Which action is most important?",
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["Stop lamotrigine immediately and provide specialized supportive care", "Continue lamotrigine with an antihistamine", "Debride all detached epidermis at bedside", "Prescribe topical acne therapy", "Discharge after oral fluids"],
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"Mucosal erosions and epidermal detachment after a high-risk drug indicate Stevens-Johnson syndrome. Immediate withdrawal and burn-unit-level supportive care reduce ongoing injury and complications.",
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"Immediately stop the culprit drug in suspected SJS/TEN and provide intensive supportive care.", "oral erosions", "10 days after starting lamotrigine", "epidermal detachment involves 8%", "FDA-LAM", "Musculoskeletal/Skin & Subcutaneous Tissue"),
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Q("necrotizing-fasciitis-surgery", "Skin and Subcutaneous Tissue", "Surgery", "necrotizing soft tissue infection",
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"A 56-year-old man with diabetes has rapidly spreading leg erythema, pain far out of proportion, hemorrhagic bullae, crepitus, and hypotension. Broad antibiotics and resuscitation are started. CT is not immediately available.",
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"Which is the most appropriate next step?",
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["Immediate surgical exploration and debridement", "Wait for CT confirmation", "Incision and drainage at the bedside only", "Topical antibiotics", "Observe response for 24 hours"],
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"Shock, disproportionate pain, bullae, and crepitus indicate necrotizing infection. Definitive diagnosis and source control require immediate exploration; imaging must not delay surgery.",
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"Suspected necrotizing soft tissue infection requires urgent operative exploration and debridement.", "pain far out of proportion", "CT is not immediately available", "broad antibiotics and resuscitation are started", "IDSA-SSTI", "Musculoskeletal/Skin & Subcutaneous Tissue")
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];
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}
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