step3/content/dynamic_questions/pilot.json

[
  {
    "externalId":"dyn-biostats-arr","version":1,"objectiveId":"biostats.absolute-risk-reduction","title":"Absolute risk reduction","system":"Biostatistics","discipline":"Biostatistics","performanceCategory":"Applying Foundational Science Concepts","physicianTask":"Interpretation of Medical Literature","difficulty":2,
    "stemTemplate":"A randomized trial follows {{size}} patients. The event rate is {{control}}% with placebo and {{treatment}}% with treatment.","leadIn":"What is the absolute risk reduction?","variables":{"size":{"type":"integer","minimum":400,"maximum":1200,"step":100},"control":{"type":"integer","minimum":18,"maximum":24},"treatment":{"type":"integer","minimum":8,"maximum":12}},"derived":{"arr":{"operation":"subtract","left":"control","right":"treatment","precision":0}},"constraints":[{"field":"arr","operator":"gt","value":0}],
    "correctAnswer":{"id":"correct","textTemplate":"{{arr}} percentage points","explanationTemplate":"ARR is control event rate minus treatment event rate."},"distractors":[{"id":"a","textTemplate":"1 percentage point"},{"id":"b","textTemplate":"30 percentage points"},{"id":"c","textTemplate":"50 percentage points"},{"id":"d","textTemplate":"100 percentage points"}],
    "explanationTemplate":"Absolute risk reduction is {{control}}% − {{treatment}}% = {{arr}} percentage points.","keyTakeaway":"ARR is the arithmetic difference between control and treatment event rates.","usmlePearl":"Keep percentages in percentage points when subtracting.","references":[{"title":"Principles of Epidemiology","publisher":"CDC","url":"https://www.cdc.gov/field-epi-manual/php/chapters/analyzing-interpreting-data.html"}],"tags":["biostatistics"]
  },
  {
    "externalId":"dyn-biostats-nnt","version":1,"objectiveId":"biostats.number-needed-to-treat","title":"Number needed to treat","system":"Biostatistics","discipline":"Biostatistics","performanceCategory":"Applying Foundational Science Concepts","physicianTask":"Interpretation of Medical Literature","difficulty":3,
    "stemTemplate":"A therapy lowers the {{outcome}} rate from {{control}}% to {{treatment}}%.","leadIn":"What is the approximate number needed to treat?","variables":{"outcome":{"type":"enum","values":["stroke","hospitalization","recurrent infection"]},"control":{"type":"integer","minimum":20,"maximum":20},"treatment":{"type":"integer","minimum":10,"maximum":10}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"10","explanationTemplate":"NNT = 1/0.10 = 10."},"distractors":[{"id":"a","textTemplate":"2"},{"id":"b","textTemplate":"5"},{"id":"c","textTemplate":"20"},{"id":"d","textTemplate":"100"}],"explanationTemplate":"The ARR is 10 percentage points, or 0.10. NNT = 1/0.10 = 10.","keyTakeaway":"NNT is the reciprocal of ARR expressed as a proportion.","usmlePearl":"Convert percentage points to a decimal before taking the reciprocal.","references":[{"title":"Understanding absolute and relative risk","publisher":"NLM","url":"https://www.ncbi.nlm.nih.gov/books/NBK63647/"}]
  },
  {
    "externalId":"dyn-biostats-test","version":1,"objectiveId":"biostats.diagnostic-test","title":"Diagnostic test characteristics","system":"Biostatistics","discipline":"Biostatistics","performanceCategory":"Applying Foundational Science Concepts","physicianTask":"Interpretation of Medical Literature","difficulty":2,
    "stemTemplate":"A screening test has very high {{metric}} in a population of {{size}} people.","leadIn":"Which statement best describes this test?","variables":{"metric":{"type":"enum","values":["sensitivity"]},"size":{"type":"integer","minimum":500,"maximum":2000,"step":100}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"A negative result helps rule out disease","explanationTemplate":"A highly sensitive test has few false negatives."},"distractors":[{"id":"a","textTemplate":"A positive result definitively rules in disease"},{"id":"b","textTemplate":"Disease prevalence must be high"},{"id":"c","textTemplate":"Positive predictive value is always 100%"},{"id":"d","textTemplate":"Specificity must equal sensitivity"}],"explanationTemplate":"High sensitivity means few affected patients test negative, so a negative result is useful for ruling out disease.","keyTakeaway":"Sensitive tests are useful to rule out when negative.","usmlePearl":"SnNout is a memory aid, not a substitute for the 2×2 table.","references":[{"title":"Evidence-Based Medicine Toolkit","publisher":"University of Alberta","url":"https://www.ualberta.ca/en/medicine/programs/lifelong-learning/evidence-based-medicine/resources/ebm-toolkit.html"}]
  },
  {
    "externalId":"dyn-cardio-af","version":1,"objectiveId":"cardio.unstable-atrial-fibrillation","title":"Unstable atrial fibrillation","system":"Cardiovascular","discipline":"Medicine","performanceCategory":"Patient Care: Management","physicianTask":"Emergency Management","difficulty":2,
    "stemTemplate":"A {{age}}-year-old patient has atrial fibrillation with a ventricular rate of {{rate}}/min, hypotension, diaphoresis, and altered mental status.","leadIn":"What is the next best step?","variables":{"age":{"type":"integer","minimum":48,"maximum":82},"rate":{"type":"integer","minimum":150,"maximum":190}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"Immediate synchronized cardioversion","explanationTemplate":"Hemodynamic instability requires synchronized cardioversion."},"distractors":[{"id":"a","textTemplate":"Oral metoprolol"},{"id":"b","textTemplate":"IV adenosine"},{"id":"c","textTemplate":"Observe for spontaneous conversion"},{"id":"d","textTemplate":"Begin warfarin and reassess tomorrow"}],"explanationTemplate":"Hypotension and altered mental status indicate instability; perform immediate synchronized cardioversion.","keyTakeaway":"Unstable tachyarrhythmia requires synchronized cardioversion.","usmlePearl":"Do not delay electrical therapy for anticoagulation in an unstable patient.","references":[{"title":"Adult Tachycardia With a Pulse Algorithm","publisher":"American Heart Association","url":"https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms"}]
  },
  {
    "externalId":"dyn-renal-hyperk","version":1,"objectiveId":"renal.hyperkalemia-ecg","title":"Hyperkalemia with ECG changes","system":"Renal","discipline":"Medicine","performanceCategory":"Patient Care: Management","physicianTask":"Emergency Management","difficulty":2,
    "stemTemplate":"A patient with kidney failure has potassium {{potassium}} mEq/L and {{ecg}}.","leadIn":"Which treatment should be given first?","variables":{"potassium":{"type":"decimal","minimum":6.6,"maximum":7.4,"step":0.1,"precision":1},"ecg":{"type":"enum","values":["peaked T waves","QRS widening"]}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"IV calcium gluconate","explanationTemplate":"Calcium stabilizes the cardiac membrane."},"distractors":[{"id":"a","textTemplate":"Oral sodium polystyrene sulfonate only"},{"id":"b","textTemplate":"Fluid restriction"},{"id":"c","textTemplate":"IV furosemide only"},{"id":"d","textTemplate":"Repeat potassium in 6 hours"}],"explanationTemplate":"ECG toxicity from hyperkalemia requires immediate IV calcium to stabilize the myocardium, followed by potassium-shifting and removal therapies.","keyTakeaway":"Give IV calcium first when hyperkalemia causes ECG changes.","usmlePearl":"Calcium protects the heart but does not lower serum potassium.","references":[{"title":"Acute Hyperkalemia in Adults","publisher":"KDIGO","url":"https://kdigo.org/conferences/acute-hyperkalemia/"}]
  },
  {
    "externalId":"dyn-endo-dka","version":1,"objectiveId":"endocrine.dka-initial-management","title":"Initial DKA management","system":"Endocrine","discipline":"Medicine","performanceCategory":"Patient Care: Management","physicianTask":"Emergency Management","difficulty":2,
    "stemTemplate":"A {{age}}-year-old with polyuria, abdominal pain, glucose {{glucose}} mg/dL, anion-gap acidosis, and dehydration is diagnosed with DKA.","leadIn":"What is the initial treatment?","variables":{"age":{"type":"integer","minimum":19,"maximum":54},"glucose":{"type":"integer","minimum":420,"maximum":680,"step":10}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"IV isotonic crystalloid","explanationTemplate":"Volume resuscitation is the first treatment."},"distractors":[{"id":"a","textTemplate":"IV bicarbonate in every patient"},{"id":"b","textTemplate":"Subcutaneous long-acting insulin only"},{"id":"c","textTemplate":"Fluid restriction"},{"id":"d","textTemplate":"Immediate hemodialysis"}],"explanationTemplate":"Begin DKA treatment with isotonic IV fluid resuscitation, then address potassium and insulin based on laboratory results.","keyTakeaway":"Restore intravascular volume first in DKA.","usmlePearl":"Check potassium before or alongside starting insulin.","references":[{"title":"Hyperglycemic Crises in Adults","publisher":"American Diabetes Association","url":"https://diabetesjournals.org/care/article/47/8/1257/156806/Hyperglycemic-Crises-in-Adults-With-Diabetes-A"}]
  },
  {
    "externalId":"dyn-pulm-asthma","version":1,"objectiveId":"pulmonary.severe-asthma-exacerbation","title":"Severe asthma exacerbation","system":"Pulmonary","discipline":"Medicine","performanceCategory":"Patient Care: Management","physicianTask":"Emergency Management","difficulty":2,
    "stemTemplate":"A {{age}}-year-old with asthma has severe dyspnea, diffuse wheezing, and oxygen saturation {{sat}}%.","leadIn":"Which inhaled treatment is most appropriate immediately?","variables":{"age":{"type":"integer","minimum":18,"maximum":60},"sat":{"type":"integer","minimum":84,"maximum":91}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"Albuterol plus ipratropium","explanationTemplate":"Severe exacerbations benefit from repeated SABA plus inhaled anticholinergic."},"distractors":[{"id":"a","textTemplate":"Salmeterol alone"},{"id":"b","textTemplate":"Inhaled corticosteroid alone"},{"id":"c","textTemplate":"Montelukast alone"},{"id":"d","textTemplate":"No bronchodilator until spirometry"}],"explanationTemplate":"Give rapid inhaled bronchodilation with albuterol and ipratropium, oxygen, and systemic glucocorticoids.","keyTakeaway":"Use SABA plus ipratropium for a severe acute asthma exacerbation.","usmlePearl":"Long-acting bronchodilators do not replace rescue therapy.","references":[{"title":"Global Strategy for Asthma Management and Prevention","publisher":"GINA","url":"https://ginasthma.org/reports/"}]
  },
  {
    "externalId":"dyn-ob-pyelo","version":1,"objectiveId":"ob.pregnancy-pyelonephritis","title":"Pyelonephritis in pregnancy","system":"Pregnancy","discipline":"Obstetrics","performanceCategory":"Patient Care: Management","physicianTask":"Pharmacotherapy","difficulty":3,
    "stemTemplate":"A patient at {{weeks}} weeks' gestation has fever, flank pain, costovertebral-angle tenderness, and pyuria.","leadIn":"What is the most appropriate management?","variables":{"weeks":{"type":"integer","minimum":14,"maximum":32}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"Hospitalize and give IV ceftriaxone","explanationTemplate":"Pyelonephritis in pregnancy is initially managed inpatient with parenteral antibiotics."},"distractors":[{"id":"a","textTemplate":"Oral nitrofurantoin as outpatient"},{"id":"b","textTemplate":"No antibiotics until culture returns"},{"id":"c","textTemplate":"Oral phenazopyridine only"},{"id":"d","textTemplate":"Immediate delivery"}],"explanationTemplate":"Pregnant patients with pyelonephritis should receive initial inpatient parenteral therapy such as ceftriaxone, adjusted to culture results.","keyTakeaway":"Treat pyelonephritis in pregnancy initially with inpatient IV antibiotics.","usmlePearl":"Nitrofurantoin does not achieve adequate renal tissue levels for pyelonephritis.","references":[{"title":"Urinary Tract Infections in Pregnant Individuals","publisher":"ACOG","url":"https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2023/08/urinary-tract-infections-in-pregnant-individuals"}]
  },
  {
    "externalId":"dyn-endo-aldo","version":1,"objectiveId":"endocrine.primary-aldosteronism-screen","title":"Primary aldosteronism screening","system":"Endocrine","discipline":"Medicine","performanceCategory":"Patient Care: Diagnosis","physicianTask":"Diagnostic Studies","difficulty":3,
    "stemTemplate":"A {{age}}-year-old has resistant hypertension and spontaneous hypokalemia with potassium {{potassium}} mEq/L.","leadIn":"What is the best initial screening test?","variables":{"age":{"type":"integer","minimum":32,"maximum":65},"potassium":{"type":"decimal","minimum":2.7,"maximum":3.3,"step":0.1,"precision":1}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"Plasma aldosterone-to-renin ratio","explanationTemplate":"The aldosterone-to-renin ratio is the recommended screening test."},"distractors":[{"id":"a","textTemplate":"24-hour urine metanephrines"},{"id":"b","textTemplate":"Dexamethasone suppression test"},{"id":"c","textTemplate":"TSH concentration"},{"id":"d","textTemplate":"Renal biopsy"}],"explanationTemplate":"Resistant hypertension plus hypokalemia suggests primary aldosteronism; screen with a plasma aldosterone-to-renin ratio.","keyTakeaway":"Use the aldosterone-to-renin ratio to screen for primary aldosteronism.","usmlePearl":"Correct hypokalemia and consider medication interference when interpreting the ratio.","references":[{"title":"Primary Aldosteronism Guideline","publisher":"Endocrine Society","url":"https://www.endocrine.org/clinical-practice-guidelines/primary-aldosteronism"}]
  },
  {
    "externalId":"dyn-neuro-sah","version":1,"objectiveId":"neuro.subarachnoid-hemorrhage-initial-test","title":"Suspected subarachnoid hemorrhage","system":"Neurologic","discipline":"Medicine","performanceCategory":"Patient Care: Diagnosis","physicianTask":"Diagnostic Studies","difficulty":2,
    "stemTemplate":"A {{age}}-year-old develops a sudden maximal-at-onset headache during {{activity}}, with vomiting and neck stiffness.","leadIn":"What is the best initial diagnostic study?","variables":{"age":{"type":"integer","minimum":38,"maximum":72},"activity":{"type":"enum","values":["exercise","sexual activity","lifting a heavy object"]}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"Noncontrast CT of the head","explanationTemplate":"Noncontrast head CT is the initial test for suspected SAH."},"distractors":[{"id":"a","textTemplate":"EEG"},{"id":"b","textTemplate":"Carotid ultrasonography"},{"id":"c","textTemplate":"Cervical spine radiograph"},{"id":"d","textTemplate":"Electromyography"}],"explanationTemplate":"A thunderclap headache suggests subarachnoid hemorrhage; obtain an urgent noncontrast head CT first.","keyTakeaway":"Start evaluation of suspected SAH with noncontrast head CT.","usmlePearl":"If suspicion remains after a negative CT, additional evaluation may be required based on timing and local protocols.","references":[{"title":"Guideline for Aneurysmal Subarachnoid Hemorrhage","publisher":"American Heart Association","url":"https://www.ahajournals.org/doi/10.1161/STR.0000000000000436"}]
  },
  {
    "externalId":"dyn-pulm-pe","version":1,"objectiveId":"pulmonary.stable-pe-imaging","title":"Stable pulmonary embolism imaging","system":"Pulmonary","discipline":"Medicine","performanceCategory":"Patient Care: Diagnosis","physicianTask":"Diagnostic Studies","difficulty":3,
    "stemTemplate":"A hemodynamically stable {{age}}-year-old has acute pleuritic chest pain, tachycardia, hypoxemia, and high clinical probability of pulmonary embolism. Kidney function is normal.","leadIn":"What is the best diagnostic test?","variables":{"age":{"type":"integer","minimum":35,"maximum":74}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"CT pulmonary angiography","explanationTemplate":"CT pulmonary angiography is first-line imaging in a stable patient without contrast contraindication."},"distractors":[{"id":"a","textTemplate":"Exercise stress test"},{"id":"b","textTemplate":"Bronchoscopy"},{"id":"c","textTemplate":"Noncontrast chest CT"},{"id":"d","textTemplate":"Coronary angiography"}],"explanationTemplate":"In a stable patient with high PE probability and no contrast contraindication, proceed to CT pulmonary angiography.","keyTakeaway":"Use CT pulmonary angiography to diagnose PE when probability is high and contrast is acceptable.","usmlePearl":"A D-dimer is most useful when pretest probability is low or intermediate.","references":[{"title":"Acute Pulmonary Embolism Guideline","publisher":"European Society of Cardiology","url":"https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Pulmonary-Embolism-Diagnosis-and-Management-of"}]
  },
  {
    "externalId":"dyn-id-meningitis","version":1,"objectiveId":"infectious.adult-bacterial-meningitis","title":"Empiric adult bacterial meningitis therapy","system":"Infectious Disease","discipline":"Medicine","performanceCategory":"Patient Care: Management","physicianTask":"Pharmacotherapy","difficulty":3,
    "stemTemplate":"A {{age}}-year-old has fever, severe headache, neck stiffness, and altered mental status. Acute bacterial meningitis is suspected.","leadIn":"Which empiric antibiotic regimen is most appropriate?","variables":{"age":{"type":"integer","minimum":19,"maximum":45}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"Vancomycin plus ceftriaxone","explanationTemplate":"This combination covers resistant pneumococcus and common adult pathogens."},"distractors":[{"id":"a","textTemplate":"Azithromycin alone"},{"id":"b","textTemplate":"Metronidazole alone"},{"id":"c","textTemplate":"Nitrofurantoin alone"},{"id":"d","textTemplate":"Wait for CSF culture before antibiotics"}],"explanationTemplate":"For a nonelderly adult with suspected community-acquired bacterial meningitis, promptly give vancomycin plus a third-generation cephalosporin; add other agents when indicated by age or immune status.","keyTakeaway":"Do not delay empiric antibiotics in suspected bacterial meningitis.","usmlePearl":"Add ampicillin when Listeria coverage is indicated.","references":[{"title":"Practice Guidelines for Bacterial Meningitis","publisher":"IDSA","url":"https://academic.oup.com/cid/article/39/9/1267/402080"}]
  },
  {
    "externalId":"dyn-psych-suicide","version":1,"objectiveId":"psychiatry.imminent-suicide-risk","title":"Imminent suicide risk","system":"Behavioral Health","discipline":"Psychiatry","performanceCategory":"Patient Care: Management","physicianTask":"Disposition","difficulty":2,
    "stemTemplate":"A {{age}}-year-old with major depression reports a plan to die by suicide tonight, has access to the means, and cannot agree to a safety plan.","leadIn":"What is the most appropriate next step?","variables":{"age":{"type":"integer","minimum":18,"maximum":64}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"Emergency psychiatric hospitalization","explanationTemplate":"Specific plan, access, and imminent intent require a protected setting."},"distractors":[{"id":"a","textTemplate":"Routine follow-up in one month"},{"id":"b","textTemplate":"Ask the patient to promise not to self-harm and discharge"},{"id":"c","textTemplate":"Start psychotherapy next week without further action"},{"id":"d","textTemplate":"Leave the patient alone while arranging transport"}],"explanationTemplate":"Imminent suicide risk requires continuous safety measures and emergency psychiatric evaluation with hospitalization, involuntarily if necessary under applicable law.","keyTakeaway":"Hospitalize patients with imminent suicide risk.","usmlePearl":"A no-suicide contract does not replace risk assessment and safety planning.","references":[{"title":"Suicide Prevention Resource Center","publisher":"SPRC","url":"https://sprc.org/effective-prevention/a-comprehensive-approach-to-suicide-prevention/"}]
  },
  {
    "externalId":"dyn-prevent-crc","version":1,"objectiveId":"preventive.colorectal-screening","title":"Colorectal cancer screening","system":"Preventive Medicine","discipline":"Family Medicine","performanceCategory":"Health Maintenance","physicianTask":"Preventive Care","difficulty":2,
    "stemTemplate":"An asymptomatic {{age}}-year-old at average colorectal cancer risk has never been screened.","leadIn":"What is the best recommendation?","variables":{"age":{"type":"integer","minimum":45,"maximum":49}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"Begin colorectal cancer screening now","explanationTemplate":"Average-risk screening begins at age 45."},"distractors":[{"id":"a","textTemplate":"Wait until age 60"},{"id":"b","textTemplate":"Screen only if symptoms develop"},{"id":"c","textTemplate":"Order annual abdominal CT"},{"id":"d","textTemplate":"No screening is recommended at any age"}],"explanationTemplate":"Average-risk adults should begin colorectal cancer screening at age 45 using an accepted stool-based or direct-visualization strategy.","keyTakeaway":"Begin average-risk colorectal cancer screening at age 45.","usmlePearl":"Test choice and interval depend on the selected screening modality.","references":[{"title":"Colorectal Cancer Screening Recommendation","publisher":"USPSTF","url":"https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening"}]
  },
  {
    "externalId":"dyn-ethics-surrogate","version":1,"objectiveId":"ethics.surrogate-decision-making","title":"Surrogate decision-making","system":"Social Sciences","discipline":"Ethics","performanceCategory":"Communication and Interpersonal Skills","physicianTask":"Legal/Ethical Principles","difficulty":3,
    "stemTemplate":"An incapacitated {{age}}-year-old has no advance directive. The legally authorized surrogate is asked to choose among treatments.","leadIn":"Which standard should primarily guide the surrogate?","variables":{"age":{"type":"integer","minimum":46,"maximum":88}},"derived":{},"constraints":[],
    "correctAnswer":{"id":"correct","textTemplate":"The patient's known values and previously expressed preferences","explanationTemplate":"Use substituted judgment when the patient's preferences are known."},"distractors":[{"id":"a","textTemplate":"The surrogate's personal treatment preferences"},{"id":"b","textTemplate":"The least expensive option regardless of benefit"},{"id":"c","textTemplate":"Whatever treatment the physician would choose personally"},{"id":"d","textTemplate":"Always provide every available intervention"}],"explanationTemplate":"A surrogate should use substituted judgment based on the patient's known values and prior wishes; if unknown, use the patient's best interests.","keyTakeaway":"Surrogates represent the patient's preferences, not their own.","usmlePearl":"Use best-interest reasoning only when the patient's preferences cannot be inferred.","references":[{"title":"Decisions for Adult Patients Who Lack Capacity","publisher":"American Medical Association","url":"https://code-medical-ethics.ama-assn.org/ethics-opinions/decisions-adult-patients-who-lack-capacity"}]
  }
]