{"version":1,"updated":"2026-11-13","note":"Original MedRise Viva cases for education only. Not medical advice. Physician review pending.","cases":[{"id":"hyperkalemia-ecg","title":"Hyperkalemia with ECG changes","rotation":"Internal medicine","microskill":"Management","stem":"A 64-year-old man on hemodialysis missed his last two sessions. He feels weak. His potassium is 7.2, and the ECG shows peaked T waves and a widening QRS.","question":"What is the first medication you give?","answer":"IV calcium gluconate (or calcium chloride), to stabilize the cardiac membrane.","accept":[["calcium"]],"wrong":[{"match":["insulin","albuterol","kayexalate","patiromer","bicarbonate","dialysis","furosemide"],"why":"That lowers or shifts potassium, but with ECG changes you protect the heart first."}],"key_clue":"ECG changes (peaked T waves, widening QRS) with potassium above 7.","discriminator":"ECG changes mean the heart muscle is unstable now. Calcium stabilizes the membrane within minutes; insulin, albuterol and dialysis lower potassium but act later.","hints":["Before you think about lowering the potassium, what does the ECG tell you about urgency?","Which treatment protects the heart muscle without changing the potassium level at all?","It is a divalent cation, given IV."],"probes":[{"q":"Calcium is in. What do you give next to shift potassium into the cells?","answer":"IV regular insulin with glucose; albuterol can be added.","accept":[["insulin"]]},{"q":"He missed dialysis. What removes the potassium from his body?","answer":"Hemodialysis.","accept":[["dialysis","hemodialysis","hd"]]}],"teach":"With hyperkalemia and ECG changes, give IV calcium first to stabilize the heart, then shift potassium into cells with insulin and glucose, then remove it. In a dialysis patient, removal means urgent hemodialysis.","teach_back":{"q":"In your own words: when potassium is high and the ECG has changed, what comes first, and why?","answer":"Calcium first, because it stabilizes the cardiac membrane.","accept":[["calcium"]]},"breakdown":[{"clue":"Peaked T waves and a widening QRS","reasoning":"The heart is at risk of an arrhythmia now.","rules":"Rules in immediate membrane stabilization; rules out waiting for a repeat potassium."},{"clue":"Missed dialysis","reasoning":"His body cannot excrete potassium.","rules":"Rules in urgent hemodialysis after you stabilize and shift."}],"partial":[]},{"id":"tension-pneumothorax","title":"Tension pneumothorax after trauma","rotation":"Surgery","microskill":"Management","stem":"A 25-year-old man is brought in after a motorcycle crash. He is short of breath, and his blood pressure is 78 over 40. Breath sounds are absent on the right, the trachea deviates to the left, and his neck veins are distended.","question":"What do you do right now?","answer":"Immediate needle decompression (or finger thoracostomy) of the right chest, without waiting for a chest X-ray.","accept":[["needle","decompress","finger"]],"partial":[{"match":["chest tube","tube thoracostomy"],"why":"A chest tube is the definitive step, but you decompress first: a tube takes longer to place."}],"wrong":[{"match":["x ray","xray","chest film","ct","imaging","ultrasound","scan"],"why":"Tension pneumothorax is a bedside diagnosis. Imaging delays treatment in a patient who is crashing."}],"key_clue":"Hypotension with absent breath sounds, tracheal deviation and distended neck veins after trauma.","discriminator":"Tension pneumothorax is diagnosed at the bedside. Imaging first wastes minutes the patient does not have; the chest tube comes after decompression.","hints":["Is this patient stable enough to leave the room for imaging?","What is pushing the trachea away from the right side?","You need to let trapped air out of the right chest within seconds."],"probes":[{"q":"After decompression, what is the definitive treatment?","answer":"Tube thoracostomy (a chest tube).","accept":[["chest tube","tube thoracostomy","thoracostomy"]]},{"q":"Why are his neck veins distended?","answer":"Rising pressure in the chest blocks venous return to the heart.","accept":[["venous return","preload","pressure","obstruct","compress"]]}],"teach":"Tension pneumothorax is an obstructive shock you diagnose clinically. Decompress the chest immediately, then place a chest tube.","teach_back":{"q":"In your own words: why don't you get a chest X-ray first?","answer":"It is a clinical diagnosis in an unstable patient, and imaging delays life-saving decompression.","accept":[["clinical","unstable","delay","time","crash","dying","shock","bedside"]]},"breakdown":[{"clue":"Absent breath sounds, trachea pushed away, distended neck veins, low blood pressure","reasoning":"Air under pressure is compressing the heart and great veins.","rules":"Rules in tension pneumothorax; rules out a simple pneumothorax and waiting for imaging."},{"clue":"Shock after trauma","reasoning":"This is obstructive shock, not only blood loss.","rules":"Rules in decompression before relying on fluids."}]},{"id":"anaphylaxis","title":"Anaphylaxis","rotation":"Emergency medicine","microskill":"Management","stem":"A 30-year-old woman develops hives, lip swelling and wheezing minutes after eating shrimp. Her blood pressure is 82 over 50.","question":"What is the first treatment, and by what route?","answer":"Intramuscular epinephrine, in the anterolateral thigh.","accept":[["epinephrine","adrenaline","epipen","epi pen"],["intramuscular","im","thigh","muscle"]],"wrong":[{"match":["diphenhydramine","benadryl","antihistamine","steroid","methylprednisolone","prednisone","albuterol","famotidine"],"why":"Those can help symptoms later, but only epinephrine reverses anaphylaxis. Giving them first delays the drug that saves her."}],"key_clue":"Skin and airway signs plus low blood pressure within minutes of an allergen.","discriminator":"Low blood pressure and wheeze make this anaphylaxis. Epinephrine treats every part of it; antihistamines and steroids are add-ons only.","hints":["Which organ systems are involved, and what does the blood pressure tell you?","One drug treats airway swelling, bronchospasm and shock together. Which one?","The first dose goes into a large muscle, not IV push."],"probes":[{"q":"Her pressure stays low after the first dose. What do you add while you repeat epinephrine?","answer":"Large-volume IV isotonic fluids, and repeat IM epinephrine every 5 to 15 minutes.","accept":[["fluid","saline","lactated","bolus","crystalloid"]]},{"q":"She takes a beta-blocker and does not respond to epinephrine. Which drug can help?","answer":"Glucagon.","accept":[["glucagon"]]}],"teach":"Treat anaphylaxis with intramuscular epinephrine first, repeated as needed, and IV fluids for low blood pressure. Antihistamines and steroids are add-ons and never replace epinephrine.","teach_back":{"q":"In your own words: why does epinephrine come before an antihistamine?","answer":"Only epinephrine reverses the shock, the airway swelling and the bronchospasm.","accept":[["shock","pressure","airway","bronch","reverse","every","all","alpha","beta","vasoconstrict"]]},"breakdown":[{"clue":"Hives, lip swelling and wheeze minutes after shrimp","reasoning":"A rapid allergic reaction involving several organ systems.","rules":"Rules in anaphylaxis; rules out simple hives."},{"clue":"Blood pressure 82 over 50","reasoning":"Distributive shock is already present.","rules":"Rules in IM epinephrine now plus fluids; rules out antihistamine-only treatment."}],"partial":[]},{"id":"opioid-overdose","title":"Opioid overdose","rotation":"Emergency medicine","microskill":"Diagnosis","stem":"A 22-year-old man is found unresponsive at a party. He has a pulse, he is breathing 5 times a minute and shallowly, and his pupils are pinpoint.","question":"What drug do you give?","answer":"Naloxone, intranasal, IM or IV.","accept":[["naloxone","narcan"]],"wrong":[{"match":["flumazenil"],"why":"Flumazenil reverses benzodiazepines and can cause seizures. Pinpoint pupils and slow breathing point to opioids."}],"key_clue":"Pinpoint pupils with breathing of 5 a minute.","discriminator":"Coma, slow breathing and tiny pupils is the opioid toxidrome. Naloxone reverses it; flumazenil does not and can provoke seizures.","hints":["Which toxidrome combines coma, slow breathing and tiny pupils?","There is a competitive antagonist at the mu opioid receptor.","It comes as a nasal spray in many first-aid kits."],"probes":[{"q":"While naloxone takes effect, what do you do for his breathing?","answer":"Open the airway and support ventilation with a bag-valve mask.","accept":[["bag","ventilat","breath","airway","bvm","oxygen"]]},{"q":"He wakes up, then becomes drowsy again 40 minutes later. Why?","answer":"Naloxone can wear off before a long-acting opioid does, so he needs observation and repeat doses or an infusion.","accept":[["wear","short","half","longer","long acting","methadone","fentanyl","recur"]]}],"teach":"Coma, slow breathing and pinpoint pupils mean opioid toxicity. Support breathing, give naloxone, then watch for recurrence, because naloxone can wear off first.","teach_back":{"q":"In your own words: which findings make you reach for naloxone?","answer":"Pinpoint pupils and slow breathing in an unresponsive patient.","accept":[["pupil","pinpoint","miosis"],["breath","respirat"]]},"breakdown":[{"clue":"Pinpoint pupils","reasoning":"Opioids cause miosis.","rules":"Rules in opioid toxicity; makes stimulant or anticholinergic toxicity unlikely."},{"clue":"Breathing 5 a minute","reasoning":"Opioids suppress the respiratory drive.","rules":"Rules in naloxone plus ventilatory support now."}],"partial":[]},{"id":"ruptured-ectopic","title":"Ruptured ectopic pregnancy","rotation":"Obstetrics and gynecology","microskill":"Management","stem":"A 27-year-old woman has sudden lower abdominal pain and lightheadedness. Her last period was 7 weeks ago. Her urine pregnancy test is positive, her blood pressure is 80 over 50, and bedside ultrasound shows free fluid in the abdomen with no pregnancy in the uterus.","question":"What is the next step in management?","answer":"Emergency surgery (laparoscopy or laparotomy) while you resuscitate her.","accept":[["surgery","surgical","laparoscop","laparotom","operating room","salpingectomy","operate"]],"wrong":[{"match":["methotrexate"],"why":"Methotrexate is only for a stable patient with an unruptured ectopic. She is in shock with blood in her abdomen."},{"match":["transvaginal","repeat","hcg","quantitative"],"why":"She is unstable with free fluid. More testing delays the operation she needs."}],"key_clue":"Positive pregnancy test, low blood pressure and free fluid with no pregnancy in the uterus.","discriminator":"Stability decides the treatment. A ruptured ectopic with shock goes to the operating room; methotrexate is only for stable, unruptured cases.","hints":["Is she stable?","What is the free fluid most likely to be?","A medication would take days to work. What works now?"],"probes":[{"q":"If she were stable, with a small unruptured ectopic, a low hCG and no fetal heartbeat, what medication could you use?","answer":"Methotrexate.","accept":[["methotrexate"]]},{"q":"If the surgeon leaves the tube in place (salpingostomy), how do you confirm all the tissue is gone?","answer":"Follow serial hCG levels until they are undetectable.","accept":[["hcg","beta","pregnancy hormone","serial","follow"]]}],"teach":"A positive pregnancy test with shock and free fluid is a ruptured ectopic until proven otherwise. Resuscitate and operate; methotrexate is only for stable, unruptured cases.","teach_back":{"q":"In your own words: what decides surgery versus methotrexate?","answer":"Whether she is stable and the ectopic is unruptured.","accept":[["stable","unstable","rupture","shock","hemodynamic"]]},"breakdown":[{"clue":"Positive hCG with no intrauterine pregnancy","reasoning":"The pregnancy is somewhere else.","rules":"Rules in ectopic pregnancy."},{"clue":"Low blood pressure with free fluid","reasoning":"The ectopic has ruptured and she is bleeding.","rules":"Rules in emergency surgery; rules out methotrexate and expectant care."}],"partial":[]},{"id":"testicular-torsion","title":"Testicular torsion","rotation":"Surgery","microskill":"Management","stem":"A 15-year-old boy wakes with sudden severe left testicular pain and vomiting. The left testis sits high and horizontal, and the cremasteric reflex is absent on that side.","question":"What is the next step?","answer":"Immediate surgical exploration with detorsion and fixation of both testes. With a classic exam, do not delay for imaging.","accept":[["surgery","surgical","explor","orchiopexy","urology","operating room","detorsion"]],"wrong":[{"match":["ultrasound","doppler","imaging"],"why":"With a classic exam, imaging delays the operation, and testicular salvage falls with every hour."},{"match":["antibiotic","ceftriaxone","doxycycline"],"why":"Antibiotics treat epididymitis, which comes on gradually and keeps the cremasteric reflex."}],"key_clue":"Sudden pain, a high-riding horizontal testis and an absent cremasteric reflex.","discriminator":"Torsion is sudden with a lost cremasteric reflex; epididymitis is gradual, often with fever or urinary symptoms. Time to surgery decides whether the testis survives.","hints":["Did this start suddenly or gradually, and what does that suggest?","What does a missing cremasteric reflex point to?","Every hour counts for this testis. Where does he need to go now?"],"probes":[{"q":"In surgery, what do you do to the right testis?","answer":"Fix it as well (contralateral orchiopexy), because the defect is usually on both sides.","accept":[["orchiopexy","fix","fixat","both","bilateral","other","anchor"]]},{"q":"After about how many hours do salvage rates fall sharply?","answer":"About 6 hours.","accept":[["six","6"]]}],"teach":"Sudden testicular pain with a high-riding testis and no cremasteric reflex is torsion. Go straight to surgical exploration and fix both testes.","teach_back":{"q":"In your own words: why skip the ultrasound when the exam is classic?","answer":"Imaging delays surgery, and the testis dies with time.","accept":[["delay","time","hour","ischemi","dies","salvage","lose"]]},"breakdown":[{"clue":"Sudden onset with vomiting","reasoning":"Twisting cuts off blood flow at once.","rules":"Rules in torsion; makes epididymitis less likely."},{"clue":"Absent cremasteric reflex, high horizontal testis","reasoning":"Classic exam findings of torsion.","rules":"Rules in surgery now; rules out waiting for Doppler."}],"partial":[]},{"id":"aortic-dissection","title":"Acute aortic dissection","rotation":"Internal medicine","microskill":"Management","stem":"A 58-year-old man with long-standing high blood pressure has sudden tearing chest pain that goes through to his back. Blood pressure is 190 over 110 in the right arm and 150 over 90 in the left.","question":"What drug do you start first?","answer":"An IV beta-blocker, such as esmolol or labetalol, to lower heart rate and blood pressure.","accept":[["beta","esmolol","labetalol","metoprolol","propranolol"]],"wrong":[{"match":["nitroprusside","hydralazine","nicardipine"],"why":"A vasodilator alone causes reflex tachycardia and more stress on the aortic wall. Start the beta-blocker first; add a vasodilator after."},{"match":["heparin","aspirin","thrombolytic","tpa","alteplase","anticoag","clopidogrel"],"why":"Treating this like a heart attack with clot drugs can be fatal in a dissection."}],"key_clue":"Tearing pain to the back with a blood pressure difference between the arms.","discriminator":"Lowering the heart rate first reduces shear force on the torn aorta; a vasodilator alone triggers reflex tachycardia. Antithrombotic drugs are dangerous here.","hints":["You want to bring down two numbers. Which one first?","Which drug class lowers heart rate and the force of each beat?","One form is given IV and is very short acting."],"probes":[{"q":"He is stable with normal kidney function. What imaging confirms the diagnosis?","answer":"CT angiography of the chest.","accept":[["ct","computed","angiogra"]]},{"q":"The dissection involves the ascending aorta. What is the treatment?","answer":"Emergency surgical repair (Stanford type A).","accept":[["surgery","surgical","repair","operat"]]}],"teach":"Suspect dissection with tearing pain to the back and unequal arm pressures. Start an IV beta-blocker first, then confirm with CT angiography; ascending dissections go to surgery.","teach_back":{"q":"In your own words: why does the beta-blocker come before a vasodilator?","answer":"A vasodilator alone causes reflex tachycardia, which increases stress on the aorta.","accept":[["reflex","tachycard","heart rate","shear","stress","force"]]},"breakdown":[{"clue":"Tearing pain radiating to the back","reasoning":"Classic description of an aortic tear.","rules":"Rules in dissection; rules out treating it as a routine heart attack."},{"clue":"40-point arm blood pressure difference","reasoning":"The tear involves a branch vessel.","rules":"Rules in dissection; rules out thrombolytics and anticoagulants."}],"partial":[]},{"id":"subarachnoid-hemorrhage","title":"Thunderclap headache","rotation":"Neurology","microskill":"Diagnosis","stem":"A 45-year-old woman has the worst headache of her life. It reached full strength within one minute while she was lifting weights. Her neurologic exam is normal.","question":"What is the first test?","answer":"A noncontrast CT of the head.","accept":[["ct","cat scan","computed tomography"]],"wrong":[{"match":["mri","magnetic"],"why":"CT is faster and very sensitive for blood early on; MRI is not the first test."},{"match":["lumbar","lp","spinal tap"],"why":"Lumbar puncture comes after a negative CT, not before."}],"key_clue":"Thunderclap onset: maximal intensity within a minute.","discriminator":"A thunderclap headache is subarachnoid hemorrhage until proven otherwise. A noncontrast CT finds most bleeds early, and a negative CT does not end the workup.","hints":["How fast did the pain peak, and what does that make you worry about?","You are looking for fresh blood around the brain. Which scan shows it fastest?","No contrast is needed."],"probes":[{"q":"The CT is normal, and it has been 10 hours since the headache started. What next?","answer":"Lumbar puncture, looking for xanthochromia or red cells that do not clear. CT angiography is an alternative.","accept":[["lumbar","lp","spinal tap","xanthochromia","angiogra"]]},{"q":"Blood is confirmed. What study finds the source?","answer":"CT angiography (or catheter angiography) to look for an aneurysm.","accept":[["angiogra","cta"]]}],"teach":"Any thunderclap headache needs a noncontrast head CT first. If it is negative and time has passed, do a lumbar puncture or CT angiography before you rule out a bleed.","teach_back":{"q":"In your own words: what feature of this headache drives the urgent workup?","answer":"It reached maximum intensity within about a minute, a thunderclap onset.","accept":[["thunderclap","sudden","minute","worst","instant","peak","onset"]]},"breakdown":[{"clue":"Peak intensity within one minute","reasoning":"Thunderclap onset suggests a bleed.","rules":"Rules in urgent imaging; rules out treating it as a migraine first."},{"clue":"Onset during exertion","reasoning":"Straining can rupture an aneurysm.","rules":"Raises suspicion for subarachnoid hemorrhage."}],"partial":[]},{"id":"bacterial-meningitis","title":"Suspected bacterial meningitis","rotation":"Internal medicine","microskill":"Management","stem":"A 34-year-old man has fever, a severe headache, a stiff neck and confusion. Because he is confused, the team wants a head CT before the lumbar puncture.","question":"What must you do before he goes to CT?","answer":"Draw blood cultures, then give dexamethasone and empiric IV antibiotics right away.","accept":[["antibiotic","ceftriaxone","vancomycin","cefotaxime","antimicrobial"]],"wrong":[],"key_clue":"Suspected bacterial meningitis with a reason to delay the lumbar puncture.","discriminator":"When a CT has to come first, antibiotics cannot wait for it. Blood cultures first, then dexamethasone and antibiotics, then the CT and lumbar puncture.","hints":["What happens to his outcome for every hour antibiotics are delayed?","Which cultures can you get in one minute without a needle in the spine?","Cultures, then treat."],"probes":[{"q":"Which empiric antibiotics fit a 34-year-old with a normal immune system?","answer":"Ceftriaxone (or cefotaxime) plus vancomycin.","accept":[["ceftriaxone","cefotaxime"],["vancomycin"]]},{"q":"What would you add if he were over 50 or immunocompromised, and why?","answer":"Ampicillin, to cover Listeria.","accept":[["ampicillin"]]}],"teach":"In suspected bacterial meningitis, never let imaging delay treatment. Draw blood cultures, give dexamethasone and empiric antibiotics, then get the CT and lumbar puncture.","teach_back":{"q":"In your own words: what is the order of events when a CT must come before the tap?","answer":"Blood cultures, then dexamethasone and antibiotics, then CT, then lumbar puncture.","accept":[["culture"],["antibiotic","ceftriaxone","vancomycin"]]},"breakdown":[{"clue":"Fever, stiff neck and confusion","reasoning":"Classic features of bacterial meningitis.","rules":"Rules in empiric treatment now."},{"clue":"Confusion means CT before the lumbar puncture","reasoning":"The tap will be delayed.","rules":"Rules in blood cultures and antibiotics before the CT; rules out waiting for spinal fluid."}],"partial":[]},{"id":"giant-cell-arteritis","title":"Giant cell arteritis","rotation":"Internal medicine","microskill":"Management","stem":"A 72-year-old woman has a new headache, pain in her jaw when she chews, and blurred vision in one eye since yesterday. Her ESR is 95.","question":"What is the next step?","answer":"Start high-dose glucocorticoids right away, before the biopsy.","accept":[["steroid","prednisone","methylprednisolone","glucocorticoid","corticosteroid"]],"wrong":[{"match":["biopsy first","wait for","biopsy before"],"why":"Waiting for the biopsy risks permanent blindness, and steroids do not erase the biopsy findings for days to weeks."}],"key_clue":"Jaw claudication and new visual symptoms in an older adult with a very high ESR.","discriminator":"Her vision is at risk, so treatment cannot wait for confirmation. Biopsy findings persist for days to weeks after steroids start.","hints":["What could this patient lose permanently in the next day or two?","Which drug class calms large-vessel inflammation fast?","Treat first, confirm later."],"probes":[{"q":"How do you confirm the diagnosis?","answer":"Temporal artery biopsy; temporal artery ultrasound is an alternative where available.","accept":[["biopsy","ultrasound"]]},{"q":"Which condition of the shoulders and hips often comes with it?","answer":"Polymyalgia rheumatica.","accept":[["polymyalgia","pmr"]]}],"teach":"New headache, jaw claudication and visual symptoms over age 50 with a high ESR is giant cell arteritis. Start high-dose steroids immediately, then arrange the biopsy.","teach_back":{"q":"In your own words: why start steroids before the biopsy?","answer":"Vision loss can be permanent, and the biopsy stays positive for a while after steroids.","accept":[["vision","blind","eye","sight"]]},"breakdown":[{"clue":"Jaw pain when chewing","reasoning":"Jaw claudication from inflamed arteries.","rules":"Rules in giant cell arteritis."},{"clue":"Blurred vision since yesterday","reasoning":"The ophthalmic circulation is threatened.","rules":"Rules in steroids now; rules out waiting for the biopsy."}],"partial":[]},{"id":"angle-closure-glaucoma","title":"Acute angle-closure glaucoma","rotation":"Emergency medicine","microskill":"Management","stem":"A 63-year-old woman walked out of a dark movie theater with a severe ache in her right eye, a headache, vomiting and halos around lights. The eye is red, the pupil is mid-dilated and does not react, and the eye feels hard.","question":"Which oral or IV drug lowers her eye pressure quickly while you call ophthalmology?","answer":"Acetazolamide (IV mannitol is another option), together with pressure-lowering eye drops.","accept":[["acetazolamide","diamox","carbonic anhydrase","mannitol"]],"wrong":[{"match":["atropine","tropicamide","dilat"],"why":"Dilating the pupil worsens angle closure."}],"key_clue":"A painful red eye with a fixed mid-dilated pupil, halos and a hard eye after time in the dark.","discriminator":"Darkness dilates the pupil and closes a narrow angle. Lower the pressure fast with acetazolamide and topical drops; never dilate.","hints":["Why would sitting in a dark theater matter for the pupil?","You need to reduce how much fluid the eye makes.","It is a carbonic anhydrase inhibitor."],"probes":[{"q":"Once the attack breaks, what procedure prevents another one?","answer":"Laser peripheral iridotomy, usually in both eyes.","accept":[["iridotomy","laser"]]},{"q":"Which eye drops must you avoid?","answer":"Dilating (mydriatic or anticholinergic) drops.","accept":[["dilat","mydria","anticholinergic","atropine","tropicamide"]]}],"teach":"Angle-closure glaucoma is an eye emergency. Lower the pressure with acetazolamide and topical drops, get ophthalmology now, and plan laser peripheral iridotomy.","teach_back":{"q":"In your own words: why did the dark theater trigger this?","answer":"Darkness dilated the pupil, which closed an already narrow drainage angle.","accept":[["dilat","pupil","angle","dark"]]},"breakdown":[{"clue":"Fixed mid-dilated pupil and a hard eye","reasoning":"Pressure inside the eye is very high.","rules":"Rules in acute angle closure; rules out conjunctivitis."},{"clue":"Symptoms after leaving a dark room","reasoning":"The pupil dilated and blocked drainage.","rules":"Rules out dilating drops as part of the exam or treatment."}],"partial":[]},{"id":"cauda-equina","title":"Cauda equina syndrome","rotation":"Surgery","microskill":"Diagnosis","stem":"A 48-year-old man has worsening low back pain with numbness between his legs and on his inner thighs. He has not urinated since this morning, and a bladder scan shows 900 milliliters.","question":"What is the next step?","answer":"An emergency MRI of the lumbosacral spine.","accept":[["mri","magnetic"]],"wrong":[{"match":["x ray","xray","physical therapy","nsaid","bed rest","ibuprofen"],"why":"Those fit simple back pain. Saddle numbness and urinary retention are red flags that need an emergency MRI."}],"key_clue":"Saddle numbness with urinary retention.","discriminator":"Back pain with saddle anesthesia and retention is cauda equina syndrome. An emergency MRI and then decompression protect bladder and leg function.","hints":["Which nerves supply the skin between the legs and the bladder?","This is a surgical emergency. Which study shows the compression?","It shows soft tissue and nerve roots best."],"probes":[{"q":"The MRI shows a large central disc herniation. What now?","answer":"Emergency surgical decompression.","accept":[["surgery","surgical","decompress","neurosurg"]]},{"q":"What do you do for the 900 milliliters in his bladder?","answer":"Place a urinary catheter.","accept":[["catheter","foley","drain"]]}],"teach":"Back pain with saddle anesthesia or urinary retention means cauda equina syndrome until proven otherwise. Get an emergency MRI and a surgical consult.","teach_back":{"q":"In your own words: which two findings turned simple back pain into an emergency?","answer":"Saddle numbness and urinary retention.","accept":[["saddle","numb","groin","between"],["urin","bladder","retention"]]},"breakdown":[{"clue":"Numbness between the legs","reasoning":"Saddle anesthesia means sacral root compression.","rules":"Rules in cauda equina syndrome; rules out simple sciatica."},{"clue":"900 milliliters of retained urine","reasoning":"Bladder nerves are affected.","rules":"Rules in an emergency MRI and decompression."}],"partial":[]},{"id":"dka-first-step","title":"Diabetic ketoacidosis","rotation":"Internal medicine","microskill":"Management","stem":"A 19-year-old woman with type 1 diabetes has vomiting and deep, rapid breathing. Her glucose is 520, bicarbonate is 9, the anion gap is 26, and serum ketones are positive. Her potassium is 4.8.","question":"What is the first step in treatment?","answer":"IV fluids with isotonic saline.","accept":[["fluid","saline","normal saline","lactated","crystalloid","bolus"]],"wrong":[{"match":["insulin"],"why":"Insulin is essential, but fluids come first; insulin before volume repair can drop the blood pressure and the potassium."},{"match":["bicarbonate"],"why":"Bicarbonate is reserved for very severe acidosis, at a pH below about 6.9."}],"key_clue":"High glucose, an anion gap acidosis and ketones in a young person with type 1 diabetes.","discriminator":"Patients in DKA are several liters short. Fluids come first; insulin follows once potassium is known to be at least 3.3.","hints":["What have the vomiting and the high glucose done to her volume?","Before you drive glucose and potassium into cells, what must you restore?","It comes in a bag."],"probes":[{"q":"If her potassium were 3.0, what would you do before starting insulin?","answer":"Replace potassium first, and hold insulin until potassium is at least 3.3.","accept":[["potassium","kcl","replete","replace"]]},{"q":"Her glucose falls to 200, but the anion gap is still open. Do you stop the insulin?","answer":"No. Add dextrose to the fluids and keep the insulin running until the gap closes.","accept":[["dextrose","d5","keep","continue","glucose to"]]}],"teach":"In DKA, restore volume with isotonic fluids first, check potassium before insulin, and keep insulin running with dextrose until the anion gap closes.","teach_back":{"q":"In your own words: what must you know before you start insulin, and why?","answer":"The potassium, because insulin drives potassium into cells and can cause dangerous hypokalemia.","accept":[["potassium"]]},"breakdown":[{"clue":"Glucose 520, bicarbonate 9, anion gap 26, ketones","reasoning":"Diabetic ketoacidosis.","rules":"Rules in DKA; rules out hyperosmolar state alone."},{"clue":"Vomiting and osmotic diuresis","reasoning":"She has a large fluid deficit.","rules":"Rules in fluids first, then insulin once potassium is known."}],"partial":[]},{"id":"eclampsia","title":"Eclampsia","rotation":"Obstetrics and gynecology","microskill":"Management","stem":"A 22-year-old woman at 34 weeks of pregnancy has a generalized seizure on the labor unit. Her blood pressure is 170 over 112, and her urine shows protein.","question":"Which medication do you give for the seizure?","answer":"IV magnesium sulfate.","accept":[["magnesium"]],"wrong":[{"match":["lorazepam","diazepam","benzodiazepine","phenytoin","levetiracetam","keppra"],"why":"Magnesium sulfate is the drug of choice to treat and prevent eclamptic seizures."}],"key_clue":"A seizure with severe-range blood pressure and protein in the urine after 20 weeks.","discriminator":"In eclampsia, magnesium sulfate works better than standard antiseizure drugs. Blood pressure control and delivery planning happen alongside it.","hints":["What makes this seizure different from epilepsy?","Which drug both treats and prevents seizures in preeclampsia?","It is an electrolyte given IV."],"probes":[{"q":"Her pressure stays at 168 over 110. What do you give?","answer":"IV labetalol or IV hydralazine, or oral immediate-release nifedipine.","accept":[["labetalol","hydralazine","nifedipine"]]},{"q":"What is the definitive treatment?","answer":"Delivery, once she is stabilized.","accept":[["deliver","birth","cesarean","c section","induction"]]}],"teach":"Eclampsia is treated with IV magnesium sulfate, plus fast-acting blood pressure control for severe-range readings, and delivery once she is stable.","teach_back":{"q":"In your own words: why magnesium instead of a standard antiseizure drug?","answer":"It works better at treating and preventing eclamptic seizures.","accept":[["better","prevent","recur","eclamp","choice"]]},"breakdown":[{"clue":"Seizure at 34 weeks","reasoning":"A new seizure in late pregnancy.","rules":"Rules in eclampsia until proven otherwise."},{"clue":"Blood pressure 170 over 112 with proteinuria","reasoning":"Preeclampsia with severe features.","rules":"Rules in magnesium sulfate and urgent blood pressure control."}],"partial":[]},{"id":"pyloric-stenosis","title":"Pyloric stenosis","rotation":"Pediatrics","microskill":"Diagnosis","stem":"A 4-week-old firstborn boy has projectile, nonbilious vomiting after every feed and is eager to eat again right after. You feel a small olive-shaped mass in his upper abdomen.","question":"What is the best test to confirm the diagnosis?","answer":"Abdominal ultrasound.","accept":[["ultrasound","sonogra"]],"wrong":[{"match":["upper gi","barium","contrast study"],"why":"An upper GI series can show it, but ultrasound comes first: no radiation, and it measures the pylorus directly."},{"match":["x ray","xray","ct"],"why":"Plain films and CT are not the test of choice; ultrasound is."}],"key_clue":"Projectile nonbilious vomiting at 3 to 6 weeks with an olive-shaped mass.","discriminator":"Nonbilious vomiting means the block is before the bile duct enters. Ultrasound shows a thick, long pylorus without radiation.","hints":["The vomit has no bile. Where must the blockage be?","Which test images a baby's abdomen without radiation?","A probe on the skin."],"probes":[{"q":"What acid-base and electrolyte pattern do you expect?","answer":"A hypochloremic, hypokalemic metabolic alkalosis.","accept":[["alkalosis"],["chlor","potass","kalem","hypochlor","hypokal","low k"]]},{"q":"What must happen before the pyloromyotomy?","answer":"Correct the fluids and electrolytes, including the alkalosis.","accept":[["fluid","electrolyte","correct","alkalosis","rehydrat"]]}],"teach":"Projectile nonbilious vomiting in a young infant with an olive mass is pyloric stenosis. Confirm with ultrasound, correct the alkalosis, then pyloromyotomy.","teach_back":{"q":"In your own words: why is the vomit nonbilious?","answer":"The obstruction is at the pylorus, before the bile enters the duodenum.","accept":[["pylor","before","above","proximal","stomach"]]},"breakdown":[{"clue":"Projectile nonbilious vomiting at 4 weeks","reasoning":"Gastric outlet obstruction.","rules":"Rules in pyloric stenosis; rules out malrotation, which causes bilious vomiting."},{"clue":"Olive-shaped mass","reasoning":"The thickened pylorus.","rules":"Rules in ultrasound confirmation."}],"partial":[]},{"id":"intussusception","title":"Intussusception","rotation":"Pediatrics","microskill":"Management","stem":"A 9-month-old girl has episodes of screaming with her legs drawn up and calm periods in between. She passed a stool that looks like red currant jelly. Ultrasound shows a target sign. She has no signs of peritonitis.","question":"What is the treatment?","answer":"Air (pneumatic) or contrast enema reduction.","accept":[["enema","pneumatic","air reduction","hydrostatic"]],"wrong":[{"match":["surgery","laparotomy","laparoscopy"],"why":"Surgery is for a failed enema, perforation, peritonitis or shock. A stable child gets enema reduction first."}],"key_clue":"Colicky pain with calm intervals, currant jelly stool and a target sign.","discriminator":"In a stable child, an enema both confirms and treats; surgery is for peritonitis, perforation or a failed reduction.","hints":["Is she stable, with no peritonitis?","Which procedure pushes the bowel back from below?","The radiologist does it."],"probes":[{"q":"When do you go straight to surgery?","answer":"Peritonitis, perforation, shock, or a failed enema.","accept":[["periton","perforat","shock","unstable","fail"]]},{"q":"In an older child, what is the most common pathologic lead point?","answer":"Meckel diverticulum.","accept":[["meckel"]]}],"teach":"Intussusception presents with colicky pain, calm intervals and currant jelly stool. In a stable child, reduce it with an air or contrast enema; operate only for peritonitis, perforation or failure.","teach_back":{"q":"In your own words: what decides enema versus surgery?","answer":"Whether there is peritonitis, perforation or instability.","accept":[["periton","perforat","stable","unstable","shock"]]},"breakdown":[{"clue":"Episodes of screaming with calm periods","reasoning":"Colicky pain from telescoping bowel.","rules":"Rules in intussusception."},{"clue":"No peritonitis, stable","reasoning":"No perforation yet.","rules":"Rules in enema reduction; rules out going straight to surgery."}],"partial":[]},{"id":"appendicitis-pregnancy","title":"Appendicitis in pregnancy","rotation":"Surgery","microskill":"Diagnosis","stem":"A 29-year-old woman who is 16 weeks pregnant has pain that began around her navel and moved to the right lower abdomen, with nausea and a low fever.","question":"What is the best first imaging test?","answer":"Graded compression ultrasound, with MRI without contrast if the ultrasound is not diagnostic.","accept":[["ultrasound","sonogra"]],"wrong":[{"match":["ct","computed","cat scan"],"why":"In pregnancy, start with ultrasound and use MRI if needed, to avoid radiation."}],"key_clue":"Pain that migrated from the navel to the right lower abdomen in a pregnant patient.","discriminator":"The imaging choice changes in pregnancy and in children: ultrasound first, MRI next, CT avoided when possible.","hints":["What is different about imaging a pregnant patient?","Which test uses no radiation and is quick at the bedside?","It uses sound waves."],"probes":[{"q":"The ultrasound cannot see the appendix. What next?","answer":"MRI of the abdomen without gadolinium.","accept":[["mri","magnetic"]]},{"q":"The MRI shows appendicitis. What is the treatment?","answer":"Appendectomy; laparoscopy is preferred and safe in pregnancy.","accept":[["appendectomy","surgery","surgical","laparoscop"]]}],"teach":"Suspected appendicitis in pregnancy starts with ultrasound, then MRI without contrast if unclear. Confirmed appendicitis is treated with appendectomy.","teach_back":{"q":"In your own words: why not start with CT here?","answer":"To avoid radiation to the fetus when ultrasound or MRI can answer the question.","accept":[["radiation","fetus","baby","pregnan"]]},"breakdown":[{"clue":"Pain moving from the navel to the right lower quadrant","reasoning":"Classic migration of appendicitis.","rules":"Rules in appendicitis."},{"clue":"16 weeks pregnant","reasoning":"Avoid ionizing radiation when possible.","rules":"Rules in ultrasound first and MRI next; rules out CT as the first test."}],"partial":[]},{"id":"pulmonary-embolism","title":"Pulmonary embolism","rotation":"Internal medicine","microskill":"Diagnosis","stem":"A 46-year-old woman, three days after knee surgery, has sudden shortness of breath and chest pain that is worse when she breathes in. Her heart rate is 118 and oxygen saturation is 90 percent. Her blood pressure and kidney function are normal.","question":"What is the best test to confirm the diagnosis?","answer":"CT pulmonary angiography.","accept":[["ct","computed","angiogra","ctpa"]],"wrong":[{"match":["d dimer","ddimer","dimer"],"why":"A D-dimer only helps when probability is low. Her probability is high, so a negative result would not rule out PE."}],"key_clue":"Sudden pleuritic pain, a fast heart rate and low oxygen after surgery, with normal blood pressure.","discriminator":"High pretest probability skips the D-dimer and goes straight to imaging. With normal kidneys and no contrast allergy, CT pulmonary angiography is the test.","hints":["Is her pretest probability low or high?","When probability is high, does a D-dimer change your plan?","It is a CT with contrast timed to the pulmonary arteries."],"probes":[{"q":"If her creatinine were 3.4, which test would you use instead?","answer":"A ventilation-perfusion (V/Q) scan.","accept":[["v q","vq","ventilation","perfusion"]]},{"q":"She becomes hypotensive from a large PE. Which treatment do you consider?","answer":"Systemic thrombolysis, such as alteplase, if there is no contraindication.","accept":[["thromboly","alteplase","tpa","fibrinoly","lytic"]]}],"teach":"With a high pretest probability of PE, skip the D-dimer and confirm with CT pulmonary angiography; start anticoagulation while you wait if bleeding risk allows. Use a V/Q scan when contrast is unsafe.","teach_back":{"q":"In your own words: when does a D-dimer help?","answer":"Only when pretest probability is low, to rule out PE.","accept":[["low"]]},"breakdown":[{"clue":"Three days after knee surgery","reasoning":"Immobility and surgery raise clot risk.","rules":"Raises pretest probability for PE."},{"clue":"Heart rate 118, saturation 90 percent, normal blood pressure","reasoning":"A stable but high-probability PE.","rules":"Rules in CT pulmonary angiography; rules out using the D-dimer to exclude PE."}],"partial":[]},{"id":"inferior-stemi","title":"Inferior STEMI","rotation":"Internal medicine","microskill":"Management","stem":"A 61-year-old man has had crushing chest pain for 40 minutes. The ECG shows ST elevation in leads two, three and aVF. He has chewed an aspirin, and this hospital has a cardiac catheterization lab.","question":"What is the definitive next step?","answer":"Emergency cardiac catheterization with primary PCI.","accept":[["pci","catheter","cath","angioplasty","stent","percutaneous"]],"wrong":[{"match":["troponin","stress test","echo"],"why":"ST elevation with ongoing pain is enough. Waiting for a troponin delays reperfusion."}],"key_clue":"ST elevation in II, III and aVF with ongoing pain.","discriminator":"An inferior STEMI needs reperfusion now. When a cath lab is available within the time goal, primary PCI is preferred over fibrinolysis.","hints":["Do you need to wait for a troponin when the ST segments are elevated?","What restores flow in the blocked artery most reliably?","The cath lab is open."],"probes":[{"q":"His pressure drops after nitroglycerin, and right-sided leads show ST elevation in V4R. What happened?","answer":"A right ventricular infarction. The right ventricle depends on preload, so avoid nitrates and give IV fluids.","accept":[["right ventric","rv","preload"]]},{"q":"If PCI were not available within 120 minutes, what would you do?","answer":"Give fibrinolytic therapy within 12 hours of symptom onset, if there is no contraindication.","accept":[["thromboly","fibrinoly","alteplase","tenecteplase","tpa","lytic"]]}],"teach":"ST elevation with ongoing pain means reperfusion now: primary PCI if it can be done in time, fibrinolysis if not. Watch inferior STEMIs for right ventricular involvement before giving nitrates.","teach_back":{"q":"In your own words: why avoid nitrates in a right ventricular infarction?","answer":"The right ventricle depends on preload, and nitrates drop preload and blood pressure.","accept":[["preload","venous return","pressure","hypotens"]]},"breakdown":[{"clue":"ST elevation in II, III and aVF","reasoning":"An inferior wall STEMI, usually the right coronary artery.","rules":"Rules in emergency reperfusion; rules out waiting for troponin."},{"clue":"Cath lab available","reasoning":"PCI can be done within the time goal.","rules":"Rules in primary PCI over fibrinolysis."}],"partial":[]},{"id":"severe-hypoglycemia","title":"Severe hypoglycemia","rotation":"Emergency medicine","microskill":"Management","stem":"A 70-year-old man who uses insulin is found unresponsive at home by paramedics. His glucose is 35, and they cannot place an IV.","question":"What do they give?","answer":"Glucagon, intramuscular, subcutaneous or intranasal.","accept":[["glucagon"]],"wrong":[{"match":["oral glucose","juice","by mouth","glucose gel","candy"],"why":"He is unresponsive and cannot protect his airway, so nothing goes by mouth."}],"key_clue":"Severe hypoglycemia in an unresponsive patient with no IV access.","discriminator":"An unconscious patient cannot take sugar by mouth. Without IV access, glucagon is the route; IV dextrose once access exists.","hints":["Can he swallow safely?","Which hormone makes the liver release glucose?","It can be given into a muscle or as a nasal powder."],"probes":[{"q":"IV access is now in place. What do you give?","answer":"IV dextrose, for example D50.","accept":[["dextrose","d50","d 50","glucose"]]},{"q":"His low sugar came from a sulfonylurea and keeps coming back. Which drug helps?","answer":"Octreotide.","accept":[["octreotide"]]}],"teach":"Severe hypoglycemia in an unresponsive patient is treated with IV dextrose if there is access, or glucagon if there is not. Never give sugar by mouth to someone who cannot protect the airway.","teach_back":{"q":"In your own words: why not give juice or glucose gel here?","answer":"He is unresponsive and could aspirate.","accept":[["aspirat","airway","unresponsive","unconscious","swallow","choke"]]},"breakdown":[{"clue":"Unresponsive with glucose 35","reasoning":"Severe hypoglycemia.","rules":"Rules in glucose replacement now; rules out anything by mouth."},{"clue":"No IV access","reasoning":"IV dextrose is not possible yet.","rules":"Rules in IM, subcutaneous or intranasal glucagon."}],"partial":[]}]}