When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

About RoundsRx -Clinical Decision Support -RoundsRx

RoundsRx

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Antibiotic Guide Analgesia Guide Sedation Guide Bowel Regimen Electrolyte Replacement Pain Management & Conversions Drug Interactions Anticoag Reversal IV Fluid Guide Inotropes Guide Vasopressors Insulin Guide Code Blue & Rapid Response Procedures Guide ECG Interpretation Lab Interpretation Radiology Quick Ref GCS Pocket Card Admission Orders & I-PASS Landmark Trials

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💎 Clinical Pearls 📊 Infographic Library 🧠 Pimp Me Quiz 🧮 Clinical Calculators 📰 What's New 🎓 Intern Survival Guide ✅ Rounding Checklists 🩺 Procedure Guides ⚡ Electrolyte Replacement 💧 IV Fluids Guide 🩸 Transfusion Guide 💓 ECG Pattern Guide 🧪 Lab Interpretation Guide 📱 QR Poster 🔗 Resources 🎙️ Channels & Podcasts 🎮 Medical Games 🏛️ Famous Cases 🎬 Media Library

ℹ️ About

Available offline

What is RoundsRx?

RoundsRx was built on a simple idea: residents should not just memorize what to do, they should understand why they are doing it. Every protocol, every drug choice, every clinical decision is grounded in the landmark trials and current guidelines that shaped it. When you understand the why, you stop cramming and start thinking like a physician.

It covers 245 clinical topics and tools across 15 rotations, from ICU protocols and cardiology to nephrology, heme/onc, and palliative care. Each topic is built around how residents actually work: pimp questions for rounds prep, clinical case scenarios, drug tables with brand names and dosing, trial citations with hover descriptions, and "updated practice" flags that highlight where old teaching has been overturned by new evidence.

Beyond clinical content, RoundsRx includes a media library with medical movies, documentaries, TV series, and recommended books for residents, plus a curated resources page with clinical guidelines, tools, and textbook recommendations, because residency is more than just medicine.

Build Stats

250

Clinical Topics & Tools

6,000+

Drug Table Entries

1,068

Pimp Questions

Rotation Pages

1,771

Trial Citations

1,161

Clinical Alert Flags

Calculators

566

Clinical Scenarios

Key Features

🔍 Smart Search

Full-text search across every word on the site, all topics, drugs, and 1,771 trial citations. Results highlight and scroll directly to the matching content.

📚 Trial Citations

1,771 trial badges with hover tooltips explaining study design, key findings, and clinical impact.

🧠 Pimp Me Quiz

1,068 attending-style questions with reveal answers -including SSC 2026 and 2026 ACC/AHA Dyslipidemia guideline updates. Filter by rotation or topic. Perfect for pre-rounds prep.

🔄 Updated Practice

1,161 clinical alert flags highlighting key warnings, updated practice, and evidence-based practice changes.

📋 Clinical Cases

34 step-by-step bedside scenarios with timelines, drug choices, and teaching points at each decision point.

🌙 Dark Mode + Offline

Full dark mode support. Works offline in the hospital -no WiFi needed.

🧮 28 Calculators

Organized by rotation -Nephrology, Cardiology, Pulmonology, ICU, GI, General. CrCl, MELD, CHA₂DS₂-VASc, PREVENT (2026), ASCVD Pooled Cohort, Wells, NEWS/MEWS, and more.

🖨️ Print-Ready

Every topic has a one-pager designed for printing. QR poster for resident lounges. Optimized print styles.

This application, including all clinical content, source code, design, and underlying data structures, is the proprietary intellectual property of RoundsRx. Unauthorized copying, redistribution, modification, reverse engineering, or creation of derivative works is strictly prohibited.

You are granted a personal, non-transferable, non-exclusive license to use RoundsRx for your own clinical education and patient care. Commercial use, resale, or republishing of any part of this application requires written permission from RoundsRx.

Changelog

v5.4 - July 23, 2026

NEW TOPIC: Cyclosporiasis (Cyclospora cayetanensis), full 8-tab view (Overview / Workup / Management / Medications / Prevention / Rounds / Summary / One Pager) under the Infectious Disease rotation, tagged 2026 OUTBREAK. Built around the active 2026 US cyclosporiasis surge (CDC Health Alert Network HAN00531): 4,173 lab-confirmed domestic cases plus more than 7,400 probable since May 1, 2026, more than 6× the prior season, with a traceback investigation of 1,645 confirmed cases across 34 states (age 2 to 95, median 44, 56% female). Source identified as shredded iceberg lettuce (Taylor Farms de Mexico) served at Taco Bell locations in Indiana, Kentucky, Michigan, Ohio, and West Virginia; all central-Mexico-sourced iceberg lettuce recalled July 17, 2026. Clinical content covers the fecal-oral (not person-to-person) transmission and why hospital contact precautions are not needed (oocysts must sporulate in the environment first), the ~7-day incubation, the hallmark prolonged, relapsing watery diarrhea with disproportionate fatigue, anorexia, and weight loss, and the central teaching trap: routine stool ova-and-parasites does NOT detect Cyclospora, so you must specifically order molecular GI PCR panel (preferred), modified acid-fast stain (variably acid-fast, oocysts 8 to 10 µm), or UV autofluorescence, and collect 2 to 3 specimens on different days because shedding is intermittent. Treatment section: TMP-SMX DS 1 tab PO BID × 7 to 10 days as the only reliably effective agent (prevents the characteristic relapse), the sulfa-allergy problem (no highly effective alternative; nitazoxanide 500 mg BID × 7d or ciprofloxacin 500 mg BID × 7d as fallbacks), and immunocompromised management (higher-dose/longer course + suppressive TMP-SMX 3×/week). Includes a Prevention tab (washing does not reliably remove oocysts; cooking kills them; nationally notifiable), 5 pimp questions, 3 bedside cases (outbreak-linked, sulfa-allergic, advanced-HIV), a Summary grid, and a printable one-pager. All clinical facts verified against CDC Cyclosporiasis clinical guidance, the CDC HAN notice, and Merck Manual Professional. Wired into the Infectious Disease rotation page next to the Hantavirus and Ebola 2026 OUTBREAK topics.
NEW: Infographic Library (56 one-page visual summaries), a new id="infographic-library" view under the Tools nav group collecting the full RoundsRx Infographic Series. 56 print-ready A4 PDFs grouped into 10 categories (Sepsis & Infection 12, Cardiovascular 10, Respiratory 7, Toxicology & Emergencies 6, Gastro & Hepatology 5, Neurology 5, Renal & Metabolic 5, Airway & Procedures 2, General ICU Care 2, Hematology 2). Each card shows a preview thumbnail and opens the vector PDF, which stays sharp when zoomed or printed. 47 of the 56 are also embedded directly in their parent topic under the One Pager tab: 28 replaced an existing HTML one-pager, 14 got a brand-new One Pager section and tab (necrotizing fasciitis, RSI, acute liver failure, malignant hyperthermia, fat embolism, PADIS sedation/delirium, fungal infections, brain death, massive transfusion, radiology quick-ref, anticoagulation reversal, hyperkalemia, antibiotics, anaphylaxis), and 5 were appended to quick-reference views that have no tab structure (ACLS, vasopressors, inotropes, electrolyte replacement, shock/differential trees). Search is preserved: where an infographic replaced an HTML one-pager, the original text was retained inside a collapsed "Text version" block, so every term stays findable through global search and readable by screen readers. All asset paths are root-relative (/infographics/...) so they resolve correctly on SPA deep links rather than 404-ing under the topic path.
Build stats refreshed: 250 topics, 727 pearls, 1,068 pimp questions, 1,771 trial citations, 1,161 alert flags, 28 calculators, 566 clinical scenarios, 56 infographics, 6,000+ drug-table entries. OG image regenerated (250 / 15 / 1,068).

v5.3 - May 27, 2026

NEW TOPIC: Ebola Virus Disease, 6-tab intern-focused view (Overview / Workup / Management / Prevention / Rounds / Summary) under Infectious Disease rotation. Built around the active 2026 Bundibugyo outbreak in DRC and Uganda (WHO PHEIC declared May 17, 2026; 121 confirmed + 17 deaths in DRC, 7 confirmed + 1 death in Uganda as of May 26, 2026; Italy travel scare returned negative). Covers the five ebolavirus species with side-by-side case-fatality and approved-MCM table making the "Inmazeb, Ebanga, and Ervebo are Zaire-only" caveat unmissable, transmission modes (including persistent virus in semen / eye / breast milk for survivors), four clinical phases (early febrile → wet/GI → critical/shock → recovery or death), triage red flags (fever + 21-day exposure to outbreak country), the CDC Identify-Isolate-Inform playbook with CDC EOC 770-488-7100, "What NOT to do until cleared" red box (no central lines, no LP, no routine bloods, no aerosol-generating procedures), differential with "always rule out malaria first" for sub-Saharan returning travelers, supportive care backbone (balanced crystalloid not large-volume NS, strict electrolyte/glucose repletion, norepinephrine first-line, empiric antimalarial and ceftriaxone), Inmazeb vs Ebanga PALM 2019 trial data with explicit Zaire-only labelling, layered PPE with trained-observer doffing as the highest-risk step, Ervebo (rVSV-ZEBOV-GP) ring-vaccination strategy with Zaire-only caveat repeated, contact tracing tiers, returning-traveler counseling, and 6 pimp questions including the "what kills patients with Ebola is not hemorrhage" framing. Wired into Infectious Disease rotation page with 2026 OUTBREAK tag.
Pimp Me: lightweight spaced-repetition controls, the quiz page now has three retention tools layered over the existing 1,061-question bank (no new content, just a smarter engine): 🔀 Shuffle (randomizes order each session to break position-memory), ★ Mark for review + ★ Review only (star weak questions and drill just those), and 👁 Hide known (✓ Got it removes mastered questions so you stop re-seeing them). Stars and known-marks persist per device via localStorage (roundsrx_pimp_v1), counts show live in the toolbar, and "Clear stars/known" resets. Navigation now walks a filtered working-list rather than the raw priority order. First step toward true interval scheduling if usage warrants it.
Nephrology: Drug Dosing in Renal Impairment reference, new id="renal-drug-dosing" section in the CKD Medications tab. Six why-driven tables (~37 drugs) covering the STOP/avoid list (NSAIDs, metformin, nitrofurantoin, glyburide, spironolactone, IV bisphosphonates, sotalol, group-I gadolinium), antibiotics (vancomycin, aminoglycosides, cefepime neurotoxicity, vanc+pip-tazo AKI, carbapenems, fluoroquinolones, TMP-SMX pseudo-Cr-rise, acyclovir), anticoagulants (apixaban as preferred DOAC + 2-of-3 reduction, dabigatran/rivaroxaban/edoxaban thresholds incl. the edoxaban >95 paradox, enoxaparin 1 mg/kg daily <30), diabetes (SGLT2i initiate ≥20/25 and continue to dialysis, glipizide-over-glyburide, insulin reduction, linagliptin no-adjust), cardiovascular (digoxin, renally-cleared beta-blockers, ACEi/ARB ≤30% Cr-rise rule, rosuvastatin max 10 if eGFR<30), and analgesia/neuro/misc (gabapentinoids, morphine M6G accumulation, allopurinol titrate-to-target, colchicine, lithium, iodinated contrast). Every row states the GFR/CrCl threshold, the action, the why, and a renal-friendly alternative ("use instead" column): e.g., acetaminophen for NSAIDs, apixaban/warfarin for the other DOACs, atorvastatin for rosuvastatin, denosumab for IV bisphosphonates, febuxostat (with CARES caveat) for allopurinol, fentanyl/hydromorphone for morphine, metoprolol/carvedilol for renally-cleared beta-blockers, group-II gadolinium for group-I. CrCl calculator linked; thresholds verified against KDIGO/ADA 2025 and current labels. Deep-linked into the section from four sibling topics where the question arises: AKI (medication review step), antibiotics (renal-dose table cross-reference), anticoagulation (DOAC renal dosing), and outpatient diabetes (metformin dose-by-eGFR).
Heart Failure: BNP / NT-proBNP interpretation section, new id="bnp-interpretation" block in the Acute HF Workup tab. Two why-driven tables, conditions that raise BNP (cardiac: HF, AFib, ACS, valvular, myocarditis; non-cardiac traps: age, CKD, PE, pulmonary HTN/COPD, sepsis, female sex, anemia/high-output) and conditions that keep it deceptively low despite real HF (obesity via NPR-C clearance, hyperacute flash edema, HFpEF, constrictive pericarditis/tamponade, compensated chronic HF). Plus a clearance-mechanism box explaining the BNP-vs-NT-proBNP differences and the ARNI trap from one fact (BNP cleared 3 ways including neprilysin; NT-proBNP renal-only): why CKD raises NT-proBNP more, obesity lowers BNP more, and why sacubitril/valsartan makes BNP unreliable so NT-proBNP is the marker to trend on Entresto. Age-adjusted NT-proBNP cutoffs included, plus a "Which to order: BNP vs NT-proBNP" decision box (equivalent for dx/prognosis so use what the lab runs; NT-proBNP if on an ARNI; lean BNP in advanced CKD; never compare values across assays, trend the same one). Five passing BNP mentions site-wide (STEMI, qr-labs, lab-guide, TACO/TRALI discriminator, and the HF workup row) deep-linked to this canonical section. ARNI-affects-BNP caveat propagated to the chronic HF GDMT topic (Congestive HF GDMT monitoring table + workup), since that topic recommends ARNI as pillar #1 while also recommending BNP trending, the two collide, so both monitoring mentions now flag "on Entresto, trend NT-proBNP not BNP" with a deep-link back to the why.
Palliative Care: intractable hiccups expanded + accuracy fix, the existing “Hiccups > 48h” subsection (id="intractable-hiccups") rebuilt into a full singultus reference, definitions (acute <48h / persistent >48h / intractable >1 month), the reflex-arc rationale for the broad differential, causes ordered by frequency (GI, drugs incl. dexamethasone, CNS/Wallenberg with stroke deep-link, phrenic-vagus irritation, metabolic), targeted workup, and a corrected treatment ladder. Clinical fix: chlorpromazine was mislabeled first-line; per current evidence baclofen and gabapentin are first-line (tolerability) with chlorpromazine the only FDA-approved agent but held in reserve (sedation, hypotension, QTc, EPS). Same correction propagated across the topic’s symptom-overview table, summary cell, and one-pager so all four mentions agree.
ITP: pseudothrombocytopenia callout, new id="pseudothrombocytopenia" box in the ITP Workup tab making it the "rule out FIRST" step for any isolated low platelet count. Covers the EDTA / GPIIb-IIIa / calcium-chelation clumping mechanism, the smear-confirms-clumps diagnostic step, and the key nuance that a manual count on the same clumped EDTA tube is also falsely low (clumps defeat any counting method), so the fix is removing the clumping, redraw in citrate (×1.1 dilution correction) or heparin, and/or warm to 37°C, not switching counting technique. Closes with why it matters (avoid needless transfusions, steroids, marrow biopsy, held anticoagulation).
Acid-Base: Cohen-Woods classification + D-lactic acidosis, new dedicated id="cohen-woods-lactic-acidosis" section in the Acid-Base topic. Two-type framework (A = hypoperfusion/hypoxia, B = everything else) with B1 (underlying disease: liver failure, malignancy, sepsis, thiamine deficiency, short bowel/SIBO), B2 (drugs/toxins: metformin, linezolid, propofol, NRTIs, β₂ agonists), B3 (inborn errors: mitochondrial, PDH deficiency). New D-lactic acidosis alert covers the SIBO/short-bowel mechanism (gut bacteria ferment carb to D-lactate, the stereoisomer humans cannot clear), episodic encephalopathy presentation, and the standard lactate assay measures L-lactate only trap (order a D-lactate level specifically). Sits inside Type B1 in Cohen-Woods.
Milk-alkali syndrome deep section in Hypercalcemia, dedicated id="milk-alkali-syndrome" breakdown (CaCO₃ antacids + milk → hypercalcemia + AKI + alkalosis triad, mechanism, classic vs modern presentation, distinguishing from other hypercalcemia causes). Cross-linked from the Acid-Base CLEVER PD "Excess alkali" row using the established showView + scrollIntoView deep-link pattern so the passing mention navigates directly to the deep explanation.
Pneumonia: severe-CAP definition + steroids-in-pneumonia sections, new id="severe-cap-definition" section makes ICU-disposition criteria explicit (IDSA/ATS major and minor criteria) so the "severe CAP" label triggers cefepime + vancomycin per SSC 2026 rather than ceftriaxone + azithromycin. New id="steroids-in-pneumonia" section covers when steroids help (severe CAP / refractory shock, CAPE COD 2023), when they do not (non-severe CAP, viral pneumonia), and which steroid + dose.
ACS Overview: 2025 guideline-changes summary section, new id="acs-2025-guideline-changes" section consolidates what changed in the 2025 ACC/AHA ACS guideline at a glance (DAPT duration shifts, P2Y12 selection nuances, routine PRECISE-DAPT/DAPT-score risk-tiered de-escalation) with tag-driven NEW / CHANGED / UNCHANGED columns following the editorial "always state guideline changes" rule.
Second SEO/indexing acceleration pass, follow-up to the v5.2 cycle: (1) ran indexnow-submit.js a second time pushing all 247 URLs to api.indexnow.org (200 OK), Bing IndexNow (200 OK), and Yandex IndexNow (202 Accepted); (2) diagnosed the GSC "Crawled - currently not indexed" validation failure (135 pending, 3 failed as of May 2, 2026) - verified via curl-as-Googlebot that the live edge function correctly serves per-URL unique title, self-canonical, unique meta description, JSON-LD MedicalWebPage schema, X-Robots-Tag: index, follow, ~18 KB of unique visible text per page, and strips 245 sibling views per request (only 1 target view div + 245 stripped placeholders served); (3) sitemap.xml lastmod bumped to 2026-05-27 only for genuinely-changed entries (homepage, dyslipidemia-guideline-2026, outpatient-lipid-management, type-2-diabetes-outpatient) - deliberately did NOT blanket-bump unchanged URLs since Google detects fake freshness and penalizes it; (4) orphan-URL cleanup: caught two stale sitemap entries (/inpatient-insulin-management and /toxicology-toxidromes-antidotes) whose view divs had been renamed to /inpatient-diabetes-management and /toxicology-drug-overdose. The edge function's safety-bail was serving the dashboard for these URLs, creating exactly the duplicate-content signal that drives "Crawled - currently not indexed". Added 301 redirects in _redirects and pulled the stale entries from sitemap.xml. Conclusion documented: "Crawled - currently not indexed" is now a quality/authority signal, not a technical bug; resolution path is backlinks + time + "Request Indexing" per-URL in GSC, not more code changes.
Build stats refreshed: 248 topics, 727 pearls, 1,061 pimp questions, 1,747 trial citations, 1,122 alert flags, 28 calculators, 563 clinical scenarios, 6,000+ drug-table entries.

v5.2 - May 7, 2026

NEW TOPIC: Hantavirus (HPS & HFRS), full 8-tab view (Overview / Workup / Management / Medications / Prevention / Rounds / Summary / One Pager) under Infectious Disease rotation. Built around the active 2026 M/V Hondius cruise-ship outbreak (Andes virus, person-to-person transmission documented, 5 confirmed + 3 suspected cases as of May 6, 2026). Covers HPS vs HFRS comparison, 2026 outbreak alert front-and-center, US epidemiology with Hackman/Arakawa context, β3-integrin endothelial pathophysiology, four phases of HPS, diagnostic triad (thrombocytopenia + hemoconcentration + immunoblasts), 11-step management package with VA-ECMO criteria (50–65% survival vs 35% without), ribavirin caveat (works in HFRS, NOT HPS), Andes airborne/droplet precautions, and a comprehensive Prevention tab with FAQ-format SEO content (CDC bleach-based cleanup, rodent-proofing, cabin protocol, traveler precautions for 2026 outbreak, healthcare worker tiers).
NEW TOPIC: Calciphylaxis (Calcific Uremic Arteriolopathy), full 7-tab view under Nephrology rotation. Covers MGP/warfarin pathophysiology, modifiable-vs-non-modifiable risk factor table, painful retiform purpura presentation, central vs peripheral lesion prognosis (~80% vs ~50% mortality), 12-step coordinated management package (sodium thiosulfate 25 g IV after each HD, switch warfarin → apixaban, stop Ca-based binders, aggressive phosphate control, calcimimetics, vitamin K, conservative wound care, multimodal pain), explicit "What NOT to Do" red box, dedicated Ca × P product formula callout with thermodynamic rationale (target < 55 mg²/dL², albumin-corrected Ca formula, KDIGO 2017 caveat), and 5 pimp questions including the warfarin-MGP mechanism.
Status Epilepticus major expansion, post-ictal LFT gotcha (AST > ALT pattern is muscle not liver), comprehensive post-ictal lab timing reference table (19 markers sorted fastest-to-slowest decay: lactate / prolactin / anion gap / WBC / cortisol / glucose / ammonia / myoglobin / troponin / AST / ALT / CK / aldolase / K⁺ / phosphate / Ca / urine myoglobin / Cr / LDH), "Why bilirubin isn't on the post-ictal list" callout (myoglobin → urine vs hemoglobin → bilirubin), GTC vs syncope vs PNES discriminator table, brand names added throughout the protocol (Ativan, Versed, Keppra, Depakote, Cerebyx, Diprivan, Ketalar, Vimpat), max doses for valproate/fosphenytoin in Phase 2, IM midazolam weight cutoff (10 mg if ≥ 40 kg, 5 mg if 13–40 kg), thiamine 100 mg IV before/with D50W in Stabilize step, "Why fosphenytoin not phenytoin" inline parenthetical (3× faster infusion, no purple-glove necrosis, less propylene-glycol cardiotoxicity, IM option). Lacosamide (Vimpat) added as Phase 2 fourth alternative (200–400 mg IV load) for benzo-refractory SE when LEV/VPA/PHT contraindicated.
NEW SECTION: Discharge & Outpatient AED Regimen in Status Epilepticus Medications tab, covers (1) decision to start AED based on recurrence risk, (2) seizure-type-specific selection table (focal / GTC / absence / myoclonic with first-line / alternatives / avoid columns), (3) maintenance dosing reference table for 10 AEDs (Keppra / Lamictal / Vimpat / Trileptal / Tegretol / Depakote / Topamax / Dilantin / Zonegran / Briviact) with side effects ordered by importance not frequency (life-threatening first, then teratogenicity, then dose-limiting, then common-tolerable, then PK), (4) special populations (pregnancy preferred lamotrigine/levetiracetam, elderly, CKD, hepatic), (5) discharge counseling checklist (state-specific driving, adherence, triggers, bone health, SUDEP), (6) drug-drug interactions (carbapenem × VPA red alert, enzyme inducers vs OCP/warfarin/DOACs/immunosuppressants, lamotrigine × VPA halve dose, lamotrigine × estrogen-OCP cycling). Empirical pyridoxine for Keppra behavioral SE clarified as supraphysiologic adjunct, not deficiency repletion.
STEMI P2Y12 rationale expanded, replaced bare "STEMI is different from NSTEMI" line with full explanation of why STEMI gets P2Y12 upfront (diagnosis certain, destination certain, CABG-needing anatomy ~3–5%, pre-loading reaches therapeutic platelet inhibition by stent deployment) vs NSTEMI defers to PCI time (~10–15% need CABG, pre-loaded prasugrel/ticagrelor force 5–7 day off-antiplatelet wait). Added ACCOAST, 2013 citation establishing that upstream prasugrel in NSTEMI is harmful.
Massive Transfusion Protocol Cycle 1 update, 5 new sections in Management tab: Whole Blood (LTOWB) as preferred initial product per AAST/ACS 2024, TBI changes the rules red alert (MAP ≥ 80, INR < 1.4, plt > 100K, hypertonic saline 3%/23.4%, no permissive hypotension), Hyperkalemia from stored blood (stored RBCs leak K⁺ to 30–40 mEq/L by day 35, washed RBCs option, dialysis if refractory), TRALI vs TACO discriminator table (mechanism, onset, vital signs, BNP, CXR, echo, treatment, mortality, with "if unsure treat as TACO first" pearl), and Anticoagulation Reversal table (apixaban/rivaroxaban → andexanet alfa with ANNEXA-4/I cite, dabigatran → idarucizumab with REVERSE-AD cite, warfarin → 4F-PCC + vitamin K with Sarode 2013 cite, UFH → protamine, LMWH → partial protamine, antiplatelets → platelets + DDAVP with PATCH 2016 caveat, fondaparinux → no specific reversal). Defining thresholds in MTP Overview now bolded for emphasis.
SEO & indexing acceleration cycle, (1) Hantavirus & Calciphylaxis added to og-tags.js edge function (per-URL title + meta description for both); (2) sitemap.xml updated with both URLs (Hantavirus priority 0.95 weekly for outbreak news, Calciphylaxis priority 0.8 monthly); (3) Bing Webmaster Tools verification meta tag added to head section (msvalidate.01 = 74DDB20FB23F08D10C5E676DAB2F59EA), site verified live; (4) BWT sitemap submitted, URL inspection submitted for Hantavirus + Calciphylaxis (Bing 100 URLs/day quota); (5) IndexNow batch script (indexnow-submit.js) pushes all 247 URLs to Bing/Yandex/IndexNow.org in one call, run twice in this cycle (pre-deploy + post-deploy with related-topics content); (6) Google Search Console sitemap resubmitted, Hantavirus + Calciphylaxis URL Inspect + Request Indexing submitted to priority queue; (7) diagnosed root cause of 122 "Alternate page with proper canonical" GSC issue (last crawl Mar 26, 2026 was before edge-function canonical rewrite was working; verified via curl-as-Googlebot that current served HTML now has correct per-URL canonical, just awaiting Google re-crawl).
Internal linking pass: Related Topics auto-injection on 179 clinical topics, every clinical-topic view now ends with a "Related Topics" footer linking to 4–6 sibling topics from the same rotation (~900 new internal-link signals across the site). Templated, idempotent (script checks for existing data-related="1" before re-inserting), uses regex-anchored injection at topic-content close. Addresses 98 GSC "Discovered, currently not indexed" pages by giving each orphan-like topic a fresh crawl path from indexed siblings. Audit-verified: 247 views, 1331 section anchors, 0 orphan tabs, 0 duplicates, 0 content quality issues.
Editorial rule formalized, side-effect lists now ALWAYS ordered by importance not frequency (hierarchy: life-threatening / boxed warnings / "stop the drug" first → pregnancy/teratogenicity → suicidal ideation/class effects → dose-limiting common SE → common-but-tolerable → PK/dosing notes). Applied retroactively to all 10 AEDs in the new outpatient AED maintenance table. PRIS expanded inline to "propofol infusion syndrome (PRIS)" across 5 site-wide first-use locations (Status Epilepticus management, Status Epilepticus rounds, Mech Vent guide, PADIS sedation, RSI). Calciphylaxis valproate redundant profile box removed once meds-table row + Step 6 interactions section covered the same content (added unique "VPA raises phenobarbital + warfarin" + "enzyme inducers lower VPA" callout to preserve the unique interaction info).
Build stats refreshed: 247 topics, 727 pearls, 1,041 pimp questions, 1,384 trial citations, 1,057 alert flags, 531 calculator references, 557 clinical scenarios.

v5.1 - May 1, 2026

NEW TOPIC: 2026 ACC/AHA Dyslipidemia Guideline -2018 vs 2026 Comparison, dedicated standalone view (mirroring the SSC 2026 comparison page) with 20-row side-by-side table covering scope (Blood Cholesterol → Dyslipidemia), risk calculator (PCE → PREVENT-ASCVD), risk bands (<5/5-7.5/7.5-20/≥20% → <3/3-<5/5-<10/≥10%), numeric primary-prevention LDL goals for the first time (PREVENT ≥10% → <70, 5-<10% → <100), secondary-prevention split into very-high-risk (<55, apoB <55) vs standard (<70), routine Lp(a) once per lifetime + apoB targets aligned with LDL goal (<55/<70/<90), early-intervention category (HeFH at diagnosis incl. age 8-10 / age ≤30 LDL ≥160 / strong family hx / high 30-yr PREVENT), expanded DM (age 30-39 if LDL ≥160 or elevated 30-yr PREVENT), parallel non-statin add-ons (ezetimibe / bempedoic acid / PCSK9i mAb / inclisiran), HIV REPRIEVE 2023 recommendation. Three tabs: Side-by-Side, Key Changes, New in 2026. Trials supporting the changes documented (FOURIER, ODYSSEY OUTCOMES, REDUCE-IT, ORION, PROMINENT, CLEAR Outcomes, REPRIEVE, PREVENT, CTT meta-analysis).
Outpatient Lipid Management refresh, Overview now leads with a brief 8-row 2018 vs 2026 comparison snippet + "→ Full 2018 vs 2026 Comparison" link to the dedicated comparison view. Replaced the prior multi-paragraph "What changed in March 2026" alert with the more scannable snippet table.
Lipid management accuracy refinement, apoB target tiers corrected to the 2026 ACC/AHA-endorsed three-tier scheme `<55 / <70 / <90` aligned with the LDL goal (very-high-risk <55 → apoB <55; standard ASCVD or high-risk primary prevention <70 → apoB <70; intermediate / borderline <90). DM age 30-39 statin expansion language corrected to the 2026 ACC/AHA criterion: "LDL ≥160 or elevated 30-year PREVENT" (replaces ADA-style "duration ≥10 yr or microvascular disease" framing). Fixes applied across the new comparison view, the existing outpatient lipid topic, and the PREVENT calculator output.
AECOPD steroid dose corrected, methylprednisolone reverted from 125 mg IV (anaphylaxis-style dose, erroneously added in v4.3) back to 60 mg IV daily = prednisone 40 mg PO × 5 days per GOLD 2026, the actual COPD-exacerbation regimen. Dexamethasone alternative corrected from 8 mg to 6 mg (8 mg ≈ 53 mg prednisone, exceeds the GOLD 40 mg target). Same drug, same route can have very different correct doses across indications.
Resistant HTN wording fix, "Adherence is the #1 reason" inverted-polarity error corrected to "Non-adherence" in 3 places (Resistant HTN tab, summary alert, Quick Reference card). The desired-behavior word was being labeled as the cause of failure.
HTN follow-up rationale added, bare "BMP q6-12 months" directive expanded with the why: monitor for thiazide effects (hypokalemia, hyponatremia, hyperuricemia) and RAAS-inhibitor effects (hyperkalemia, Cr bump). Recheck within 1-2 weeks of any uptitration.
Insulin DKA drip dose alignment, DKA case examples and step-by-step now state both ADA-acceptable patterns: no bolus + 0.14 units/kg/hr, or 0.1 u/kg bolus + 0.1 u/kg/hr drip. Removed the "no bolus + 0.1 u/kg/hr" hybrid (under-dosed because it omits the loading effect of the bolus).
Other clinical accuracy fixes, PE prevalence in AECOPD corrected from "up to 25%" to "~12-16%" (Aleva 2017); PRORATA 2010 (sepsis ICU) replaced with ProHOSP 2009 for PCT in AECOPD; asthma NIV ">80% avoid intubation" corrected to "65% RR reduction" (Cochrane Osadnik 2017); asthma NIV starting IPAP corrected from 8-10 to 10-12 (BTS); ARDS Munshi 2017 tooltip rewritten (was a multiple-myeloma paper); AHF ADVOR result clarified ("12% absolute increase, NNT <9, RR 1.46" replaces the ambiguous "46% more decongestion"); Adrenal Crisis case scenario reversed (give dexamethasone if checking cortisol, does not cross-react with cortisol assay; AVOID hydrocortisone, which does cross-react).

v5.0 - April 28, 2026

NEW TOPIC: Outpatient Lipid Management, 7-tab view built around the 2026 ACC/AHA Multisociety Dyslipidemia Guideline (released March 13, 2026). Covers the 5 statin indications (clinical ASCVD, severe LDL ≥190, DM, primary prevention by PREVENT, NEW early-intervention category for HeFH / age ≤30 LDL ≥160 / strong family hx / high 30-yr PREVENT), 2026 LDL targets (very-high-risk <55 / standard ASCVD <70 / primary prev <70 high / <100 intermediate), routine apoB and Lp(a) testing, "lower for longer" cumulative-exposure framing, and explicit "vs 2018 guideline" comparison columns with NEW / CHANGED / EXPANDED / EARLIER START / UNCHANGED tags on every row. Wired into Cardiology and Ambulatory rotation pages plus search index.
PREVENT calculator integration, every PREVENT body-text mention in the Lipid topic (21 calc-links across headline, alerts, indications table, LDL targets table, risk enhancers, USPSTF screening, initial labs, statin algorithm, TG management, pimp answers, case scenarios, and summary grid) wired to the 2026 PREVENT calculator. ASCVD/PCE references kept only where the historical 2018 comparison is intentional.
"Choose intensity by 2026 thresholds" decision matrix, expanded the algorithm step from a single sentence into a 3-row table mapping high / moderate / lifestyle-only to specific 2026 indications and default doses, plus "start at indicated intensity, don't titrate up" (CTT 22%/39 mg/dL framing) and "modify drug choice for special populations" (Asian rosuva 5 mg, eGFR <30 rosuva max 10, HIV on PI, transplant on cyclosporine, pregnancy, frail elderly).
Atorvastatin 40 vs 80 mg callout, new collapsible in the Medications tab covering 8 scenarios (ACS/post-MI → 80 with PROVE-IT/MIRACL, very-high-risk ASCVD → 80, not at goal at 4-12 wk → escalate, HeFH high baseline → 80, primary prev PREVENT ≥10% → 40, stable CAD → 40, elderly → 40, drug-interaction risk → 40 or switch to rosuva), plus dose-response flattening explanation and rosuva 20 vs 40 parallel.
Lipid topic collapsibles, converted "Two paths to LDL <55" decision tree, "Risk-Enhancing Factors", and "Lifestyle Interventions" tables to <details> blocks for visual density. Default closed; click ▶ to expand. Search index still finds them via textContent.
2026 framework consistency fixes, Case 1 relabeled from old PCE "borderline 5-7.5%" to PREVENT "intermediate 5-<10%" (with numeric LDL <100 goal); fasting/non-fasting alert updated to reference 2026 guideline; lipid panel row + DM row updated to say "PREVENT calculator inputs" / "regardless of PREVENT score"; TG management row calc-link relabeled from "ASCVD" to "PREVENT".
Layout fix: double scrollbar, body locked to viewport so only the main content scrolls; sidebar and topbar stay fixed.
Outpatient Diabetes refinements, SU row expanded with "why not first-line" rationale; comorbidity-driven drug-selection table clarified add-on vs replace metformin; T1/T2 abbreviations expanded to T1DM/T2DM in screening tables.
6 new lipid pearls framed as attending-on-rounds pimps: gemfibrozil + statin rhabdo (cerivastatin withdrawal), atorva 80 + ezetimibe escalation logic (IMPROVE-IT), SAMSON nocebo on statin "intolerance", Vascepa pure EPA vs OTC fish oil (REDUCE-IT vs STRENGTH), HeFH workup on LDL ≥190 + premature family CAD, Lp(a) once-per-lifetime + 2026 very-high-risk classification. Library now at 718.
Build stats refreshed: 245 topics, 727 pearls, 1,022 pimp questions, 1,316 trial citations, 962 alert flags, 31 calculators, 560 clinical scenarios, 6,000+ drug-table entries.

v4.9 - April 26, 2026

NEW TOPIC: Outpatient Hypertension Management, 8-tab view covering ACC/AHA 2017 staging, workup with the lab "what changes management" depth (BMP, lipids, A1c, TSH, UACR, ECG, echo all with eGFR/A1c/TSH cutoffs and concrete decision points), drug selection by compelling indication, comprehensive Resistant HTN evaluation, and Antihypertensives in CKD & AKI section (atenolol/nadolol/sotalol AVOID list, RAAS hold list during AKI, IV options). Wired into Cardiology and Ambulatory rotation pages plus search index.
NEW CALCULATOR: ASCVD 10-Year Risk, full ACC/AHA Pooled Cohort Equation with all four race/sex coefficient sets (white men/women, AA men/women). Replaced the previous broken stub. Returns risk %, category (Low/Borderline/Intermediate/High), and exact statin + antihypertensive recommendation. Linked from every "ASCVD risk" mention site-wide via calc-link spans.
ADHF: Diuretic Escalation Ladder, 7-step escalation with acetazolamide (ADVOR 2022, 46% more decongestion), SGLT2i (EMPULSE/EMPAG-HF 2022), tolvaptan (EVEREST 2007), hypertonic saline (SMAC-HF 2011), plus the albumin + furosemide sandwich and sequential nephron blockade with mechanism explanations. Step 0 reversible-causes checklist (NSAIDs, hypotension, gut edema, RAS, hypothyroid, hypoalbuminemia) and red "what NOT to do" alerts (renal-dose dopamine ROSE-HF 2013, nesiritide ASCEND-HF 2011).
HF Medications: 4 new acute agents added to the Acute Agents table, chlorothiazide IV (Diuril), acetazolamide (Diamox + ADVOR cite), tolvaptan (Samsca + EVEREST cite), norepinephrine (SOAP II 2010 cite), IV ferric carboxymaltose (AFFIRM-AHF 2020 cite). Added "Meds to Come OFF at Admission" table (NSAIDs, non-DHP CCBs, TZDs, saxagliptin, gabapentinoids, high-dose steroids, class IC anti-arrhythmics, excess IVF) and red "Cardiogenic shock exception" callout listing exactly which GDMT drugs hold/start/continue and the resumption order.
Post-Cardiac Arrest: Secondary Prevention ICD & Disposition, new section in the Management tab citing AVID 1997 / CIDS 2000 / CASH 2000. When ICD IS indicated, when it's NOT (reversible causes including post-MI revasc, electrolytes, drug-induced QT, commotio cordis), timing rules with DINAMIT 2004 / IRIS 2009, and a Before-Discharge Checklist with VEST 2018 LifeVest bridge option. Cross-linked from the ACLS view's ROSC checklist.
Pneumothorax: Detailed Causes, full differential by category (primary spontaneous, secondary obstructive/infectious/cystic-bullous/ILD/connective tissue/special, traumatic, iatrogenic) with imaging and demographic clues plus a high-yield clue patterns alert (catamenial right-sided around menses, LAM with renal AMLs, BHD with skin/renal findings, HIV bilateral PTX).
Mech Vent Guide: Oxygen Dissociation Curve, new 40-50-60 / 70-80-90 rule section with the "SpO2 minus 30 ≈ PaO2" bedside shortcut, the knee at SpO2 90 / PaO2 60, curve shifts (CADET-face-Right mnemonic), and the two pulse-ox traps (CO poisoning needs co-oximetry, methemoglobinemia stuck at ~85% needs methylene blue).
RSI: Best Used For, added a "Best Used For" column to the Induction Agents comparison (etomidate for stable / head injury, ketamine for asthma / sepsis / awake intubation, propofol for status epilepticus / stable elective, plus a midazolam row) and a "Best Used For" row to the Paralytic comparison. New "Quick which agent decision rules" alert with per-agent rationale for 7 common scenarios.
HTN Outpatient: Why BBs aren't first-line, new collapsible explaining the central aortic vs brachial pressure mismatch (CAFE 2006 / ASCOT-BPLA 2005), other BB disadvantages, and an 11-row "When BBs ARE indicated" table covering HFrEF, post-MI, AFib rate control, stable angina, aortic dissection, thyrotoxicosis, pregnancy (labetalol), migraine, essential tremor, pheochromocytoma (after alpha-block), resistant HTN.
Pearl-of-the-Day banner now filters to ~270 priority-1/priority-2 curated pearls (not all 712), and rotation interval scales with pearl length (10s short pearls to 45s long pearls so residents can finish reading). Backfilled priority tags across 4 batches in the library.
Search engine: every word findable, removed 25,000-char section truncation (entire section content now indexed), lowered body-match threshold so single mentions surface (was requiring 5+ hits), stripped HTML markup from pearl indexing to prevent <strong>-tag false positives. <details> collapsibles still indexed because textContent ignores display state.
3 new pearls: albumin + furosemide sandwich (Nephrology · Diuretic Resistance), sequential nephron blockade (Nephrology · Diuretic Resistance), oxygen dissociation rule of thumb (Pulmonology · ABG). Library at 712 entries.
Medical accuracy fixes: BB initiation timing in ADHF moved from Day 1 to Day 3-5 (resolves contradiction with pimp answer), empagliflozin HF dose corrected to 10 mg only (was "10-25 mg"), PARADIGM-HF endpoint reworded to composite (CV death + HF hosp 20% RRR, not death alone), GDMT four-pillars table SGLT2i row completed (was missing 2 cells), metolazone dose range standardized to 2.5-10 mg, milrinone t½ wording disambiguated.
Build stats refreshed: 245 topics, 712 pearls, 1,015 pimp questions, 1,316 trial citations, 932 alert flags, 28 calculators.

v4.8 - April 18, 2026

Main search engine now indexes every word in all 702 clinical pearls, pearl hits appear directly in site-wide results and deep-link into the Pearls Library with the query pre-applied
Expanded empiric sepsis antibiotic side-effect tables with main side effects bolded and ordered by clinical importance: meropenem (VPA interaction + seizure risk factors), cefepime (cefepime-induced neurotoxicity with NCSE + EEG findings), pip-tazo (AKI with vanc, false-positive galactomannan, hypokalemia mechanism), vancomycin (flushing syndrome, formerly "Red Man"), linezolid (serotonin syndrome + optic neuritis), metronidazole (disulfiram + cerebellar syndrome MRI findings)
Added 3 new clinical pearls: PEth (alcohol biomarker of choice in transplant evaluation), carbapenem–valproate interaction (breakthrough seizures/SE, bridge to levetiracetam), hypothermic resuscitation (warmed NS over LR, cold liver cannot clear lactate)
Major SEO pass: fixed 52 navigation anchors from javascript:void(0) → real /path hrefs, unlocking 273 previously-uncrawlable URLs for Googlebot discovery. Dashboard link canonicalized to / to prevent duplicate-content issues
Refreshed Clinical Pearls Library meta description with keyword expansion across 12 rotations for SEO

v4.7 - April 16, 2026

Recounted and refreshed build stats: 244 topics, 1,045 pimp questions, 1,424 trial citations, 928 alert flags
Clinical pearls library refined, 700 curated high-yield pearls across 15 rotations, each rewritten in the site's actionable bedside tone
About page polish: version bump, build date and "Last updated" timestamp refresh

v4.6 - April 13, 2026

SSC 2026 accuracy audit: corrected hydrocortisone timing (removed erroneous "4-hour" threshold - guideline specifies "ongoing vasopressor requirement," not a specific wait time; 4h was trial enrollment criteria from ADRENAL/APROCCHSS)
Fixed albumin recommendation: SSC 2026 reversed from 2021 - now suggests crystalloids alone over crystalloids + albumin for initial resuscitation (exceptions: large crystalloid volumes, cirrhosis)
Fixed norepinephrine recommendation strength: SSC 2026 downgraded NE from strong ("recommend") to conditional ("suggest") - still first-line but weaker certainty
Added MAP 60-65 mmHg target for adults ≥ 65 years (new SSC 2026 recommendation, previously one-size-fits-all ≥ 65)
Added prolonged beta-lactam infusion: SSC 2026 recommends (strong, moderate certainty) prolonged infusion for maintenance over bolus dosing
Added dynamic fluid responsiveness measures (PLR, SVV, PPV) - SSC 2026 suggests over physical exam or static measures alone
Added blood purification: SSC 2026 suggests against hemoperfusion, high-dose hemofiltration, and plasma exchange
Added post-30 mL/kg fluid strategy: SSC 2026 suggests either liberal or restrictive approach based on individual factors
Updated SSC 2026 comparison topic with 3 new rows (beta-lactam infusion, fluid responsiveness, blood purification) and 4 new cards in New Topics section
Corrected steroid language across 15+ locations site-wide (sepsis, pressors, corticosteroids, SSC comparison, changelog, loading tips, trial cards)
Corrected steroid attribution: the reversal of the 2016 anti-steroid stance happened in 2021, not 2026. 2026 maintained the 2021 position. Replaced "7 Biggest Changes" card #4 (steroids) with prolonged beta-lactam infusion (an actual new 2026 change)

v4.5 - March 15, 2026

Expanded 13 thin clinical topics with new pimp questions, trial citations, clinical scenarios, comparison tables, and alert boxes: Small Bowel Obstruction, Transfusion Reactions, Brain Death, Headache/Migraine, Hypernatremia, RTA, Alcoholic Hepatitis, Necrotizing Fasciitis, Stable Angina/Chronic CAD, Tuberculosis, Trauma Primary/Secondary Survey, Family Meeting Framework, Prognostication Tools
Added +73 pimp questions, +88 trial citations, +24 clinical scenarios, +17 alert boxes across expanded topics
New tables: stress test selection (Stable Angina), PPD interpretation cutoffs (TB), GCS scoring (Trauma), damage control surgery phases (Trauma), functional decline trajectories (Prognostication), essential phrases for difficult conversations (Family Meeting)
Improved search: typeahead prefix matching for 2+ char queries, full-word highlighting in content, full-text index expanded to 25,000 chars
Added HSTS header, image lazy loading, PWA shortcuts, dns-prefetch, updated sitemap dates
Expanded Code Status & Advance Directives: +6 pimp Qs, 6 trial citations (Ehlenbach, Temel, Wright, Kaldjian, Sykes, Quill), 3 alert boxes, fixed truncated pimp answer
Expanded Nephrotic vs Nephritic Syndrome: +7 pimp Qs, 8 trial citations (MENTOR, RAVE, MAINRITSAN, ALMS, AURORA, Lionaki), 4 alert boxes, carousel wrapper for clinical examples
Expanded 6 top-25 inpatient topics: DVT Prophylaxis (+13 trials), Lower GI Bleed (+8 trials, +4 alerts), Chest Pain (+11 trials, +4 alerts), Falls/Delirium (+9 trials, +4 alerts), Alcohol Withdrawal (+5 trials, +4 alerts), Acute Abdomen (+5 trials, +4 alerts)
Expanded UTI & Pyelonephritis: +5 pimp Qs, +9 trial citations, 3 alert boxes, fixed Workup and Quick Reference sections (were incorrectly showing C. diff content)
Expanded Opioid Rotation & Conversion: +5 pimp Qs, +12 trial citations, 3 clinical scenarios, 2 alert boxes (fentanyl patch conversion, naloxone co-prescribing)
Expanded Cellulitis & Skin Infections: +5 pimp Qs, +10 trial citations (Talan NEJM 2016, PATCH I/II, Wong LRINEC, Hepburn, Daum NEJM 2017)
Expanded VTE Prophylaxis & Treatment: +9 pimp Qs covering Padua, Wells, PERC, age-adjusted D-dimer, cancer VTE, tPA, HIT, apixaban vs warfarin
Expanded Cholangitis & Cholecystitis: +8 trial citations (TG18, Khashab, ACDC, PONCHO, Elmunzer, Van Lent, ACR, SIS/IDSA)
Expanded Gallstone Pancreatitis: +5 pimp Qs, +4 alert boxes, trial citations (WATERFALL, Li 2013, AGA 2018, Bakker PYTHON, ACR, Elmunzer)
Updated build stats: 1,034 pimp questions, 1,412 trial citations, 940 alert flags, 574 clinical scenarios
Service worker cache bumped to v13

v4.4 - March 12, 2026

Fixed 7 duplicate element IDs across Corticosteroids, Cardiogenic Shock, Inpatient Insulin, Thyroid Storm, Hemoptysis, IBD, and Acute Abdomen views (renamed conflicting section-anchors)
Fixed 19 views with orphaned content floating outside section-anchors (pancytopenia, mitral regurgitation, falls, hypertensive emergency, C. diff, hyponatremia, HIV, GBS, myasthenic crisis, TLS, transfusion, HIT, neutropenic fever, hypercalcemia, gout, preventive care, hyperkalemia, mesenteric ischemia, and more)
Fixed 14 unbalanced views with missing closing div tags
Improved search engine: scaled bodyCount threshold prevents generic views from appearing in short-query searches; search now scrolls directly to highlighted text match
Fixed 14 unclosed section-label divs causing oversized full-text search index titles
Updated build stats: 908 pimp questions, 1,208 trial citations, 853 alert flags, 529 clinical scenarios
Service worker cache bumped to v9

v4.3 - March 11, 2026

New topic: Corticosteroids (Endocrinology) with full steroid equivalency table, glucocorticoid vs mineralocorticoid potency comparison, clinical use guide (15 scenarios), side effects by system, tapering protocols, and 6 pimp questions
Updated homepage tagline: "Know Why, Not Just What" / "The why behind every decision"
Added relative adrenal insufficiency (CIRCI) to Corticosteroids clinical use table with SSC 2026 guideline (steroids suggested for refractory septic shock)
Added dexamethasone vs hydrocortisone alert to Adrenal Crisis diagnosis section (dex does not interfere with cosyntropin stim test)
Improved search engine: fuzzy typo tolerance now applies to full-text search (not just curated entries), section text index expanded from 2000 to 5000 chars
Updated steroid equivalency table in Pain Management & Conversions: corrected mineralocorticoid potencies, added trial stickers, and linked to full Corticosteroids topic
Added 12+ trial citation stickers across Corticosteroids topic (SSC 2026, APROCCHSS, ADRENAL, REDUCE, EULAR, ATA, Endocrine Society, de Gans, Liggins & Howie, ACR, RABBIT 2, GOLD)
Updated COPD exacerbation steroid recommendation to include methylprednisolone 125 mg IV with GOLD 2024 citation
Updated build stats: 242 topics, 969 pimp questions, 999 trial citations, 850 alert flags

v4.2 - March 7, 2026

Bing SEO: verified site with Bing Webmaster Tools, submitted sitemap, set up IndexNow key file for real-time URL indexing
Automated bulk URL submission: all 241 URLs pushed to Bing IndexNow API (HTTP 200)
Schema.org structured data expanded: WebSite + SearchAction, Organization, WebApplication JSON-LD blocks added to head; MedicalWebPage enriched with datePublished, dateModified, lastReviewed
Fixed critical rendering bug: missing <script> tag was causing ~250 lines of JS (back button, recently viewed, share, copy protection) to render as raw text on every page
Removed orphaned RA Monitoring content that was bleeding into the Endo rotation view
Removed 3 more orphaned monitoring blocks: HF Monitoring inside HCM, Mesenteric Ischemia Monitoring inside PFT, Pleural Effusion Monitoring inside OSA
Fixed 3 unbalanced views (hypertrophic-cardiomyopathy, pulmonary-function-tests, obstructive-sleep-apnea), all 242 views now structurally balanced
Service worker cache bumped to v5

v4.1, April 1, 2026

Full-text search engine: every word on the site is now searchable, not just topic titles. Lazy-built index covers all 240 views and 1,300+ sections
Search highlight: clicking a result navigates to the exact text match with a purple pulse animation that auto-clears after 4 seconds
Fixed 5 unbalanced views (COPD, Asthma, Massive Transfusion, Pancytopenia, Intra-abdominal Infection) and 1 nested view (Chemotherapy Toxicity was swallowed inside Pancytopenia)
Fixed 8 unclosed carousels: content was trapped inside last carousel card in TTM, Tamponade, Pulmonary HTN, IBD, Cholangitis, Metabolic Alkalosis, ICH, and Acute Abdomen
Dynamic rendering for SEO: edge function now strips non-target views for search crawlers so each URL serves unique HTML content, fixes Google "duplicate content" and "alternate page with canonical" indexing issues
Unified topic count to 240 across all meta tags (og:description, twitter, Schema.org, manifest, were inconsistent at 175/232/239/241)
Added 9 missing pages to sitemap (APS, CLABSI, HSV, Shingles, IAI, Syncope, Syphilis, VTE, Shift Tracker)
Fixed manifest.webmanifest: split maskable icon entries per Google PWA guidelines
Merged cellulitis monitoring into Rounds section, removed last stray monitoring tab
Added inline hidden attribute + display:none to all non-active views to prevent content bleed-through during progressive rendering
Service worker cache bumped to v4
Corrected build stats: 962 pimp questions, 961 trial citations, 825 alert flags, 23 calculators, 544 clinical scenarios

v4.0, March 31, 2026

New topic: Syncope -full view with risk stratification (SFSR, CSRS, ROSE), workup algorithm, cardiac vs vasovagal management, 6 pimp questions, clinical examples, and one-pager
New topic: VTE Prophylaxis & Treatment -full view with Padua score, Wells DVT/PE, PERC rule, age-adjusted D-dimer, acute treatment (DOACs, heparin, warfarin), thrombolysis criteria, and cancer/HIT/pregnancy special situations
Fixed 22 structurally imbalanced views causing content bleed-through across pages (DKA content was leaking into Landmark Trials and other views)
Fixed toxicology view: removed corrupted HTML fragment breaking tox-management section
Fixed pancytopenia view: repaired malformed pancy-summary section tag, removed orphaned monitoring content from carousel
Removed 40 orphan monitoring sections (514 lines) left over from monitoring merge
Fixed 18 unclosed carousel divs causing content to render inside last carousel card
241 total views, 0 structural issues, 0 orphan tabs

v3.9, March 31, 2026

New ID topics: Herpes Simplex (HSV), Syphilis, Herpes Zoster (Shingles), Septic Arthritis, CLABSI & Line Infections, Intra-Abdominal Infections, full views with overview, workup, management, medications, rounds, summary, and one-pager
Fixed Cellulitis topic: repaired truncated content, added severity classification table, IV→PO criteria, and recurrence prevention with PATCH I trial
Landmark Trials Library: added detail summaries (N=, key facts, conclusion) to 150+ trial cards across all categories
Removed P-values/HRs/CIs from 2025–2026 trial cards, replaced with concise clinical conclusions
All trial card categories completed: Sepsis & Critical Care, ARDS & Ventilation, Airway & Sedation, Cardiology (ACS, HF, Shock, AF, HTN), Pulmonology, Post-Cardiac Arrest, Status Epilepticus, Neurology, GI & Hepatology, Diabetes & Endocrine, Nephrology, Rheumatology, Infectious Disease, COVID-19, Oncology, Hematology & Transfusion, IV Fluids & Resuscitation

v3.8, March 30, 2026

Fixed mnemonic formatting: bold first letters now display inline with words across all mnemonics (MUDPILES, HARDUPS, LEMON, CRAB, SNOOP, ABCDEF, CHA₂DS₂-VASc, 7 P's of RSI, HEPATICS, CREST, ABVD, and more)
CSS fix: alert-box strong tags changed from display:block to display:inline, mnemonic letters no longer stack above words
BiPAP settings guide and ventilator modes sections now collapsible to save vertical space
NIV contraindications condensed from 7-line list to single-line alert
Airway & Ventilator Management: updated meta title and description to reflect full topic scope

v3.7, March 30, 2026

Expanded 3 thin clinical topics: Non-Opioid Symptom Management, Diabetic Foot Infection, SVC Syndrome (60–100 lines → 450–580 lines each)
SEO: JSON-LD MedicalWebPage structured data injected per topic via edge function
SEO: aggressive CSS injection, Googlebot now sees only the target view per URL
Sitemap: all lastmod dates updated, 2 orphaned URLs removed, 1 slug corrected
Fixed 6 unbalanced views (AKI, Upper GI Bleed, Falls Risk, RA, Antibiotics, Pneumothorax)
Resolved 13 duplicate section IDs across 5 views (hypercalcemia, necrotizing fasciitis, palliative extubation, acid-base disorders, toxicology overdose)

v3.6, March 29, 2026

106 trial citations converted to styled spans with hover descriptions
RCT Library renamed to Landmark Trials, reorganized by topic, ordered by importance, 104 new trial cards added
Post-Cardiac Arrest: H's & T's updated to 6 H's and 6 T's (added Hypoglycemia, Trauma)
Surviving Sepsis Campaign 2026: full guideline names in comparison headers and tabs
Full structural audit: fixed 163 orphaned sections, 13 duplicate IDs, 4 unclosed topic-tabs, 5 misplaced section blocks
~120 missing tab buttons added across 80+ views
Removed misplaced content: VTE sections from Falls Risk, CKD from GCS, note templates from Radiology, syncope from Valvular HD
Fixed COPD, OSA, Pneumothorax, Chemotherapy Toxicity, Lymphoma: stray HTML in topic-tabs cleaned
Upper & Lower GI Bleed: structural fixes, missing tab buttons, expanded content
QR Poster: real QR code image, updated stats
Favicon: added favicon.ico for Google indexing, updated manifest with PNG icons

v3.5 -March 28, 2026

Copyright protection: Terms of Use, domain lock, anti-copy measures, invisible watermarks
Architecture details removed from About page for security
Scrollable changelog in About page
938 pimp questions, answers shortened for succinct rounds-style delivery
18 Antibiotic De-Escalation examples with culture-directed narrowing table
Sepsis clinical examples expanded: 5 cases with Antibiotic Stewardship guidance
Pimp questions now in carousel format with indigo theme
96 related topic cross-links for improved navigation
SEO improvements: OG locale, image dimensions, cache headers, sitemap lastmod dates
Edge function updated for better Google indexing (unique content per URL)
Structural fixes: 14 unbalanced views, 3 duplicate views, 6 inverted views resolved
Copyright footer on all pages

v3.4 -March 28, 2026

6 topics expanded: DVT Prophylaxis, Contrast Nephropathy, Burns, Tuberculosis, Renal Tubular Acidosis, Dermatomyositis/Polymyositis
18 new clinical example carousels with horizontal scroll navigation
13 new pimp questions across expanded topics
6 new mnemonics: THROMBOSIS (DVT), RIPE + side effects (TB), K+ pattern (RTA), HELIOGRAMS (DM), SHE (PE Virchow triad), 5 I's (DKA)
New carousel system for clinical case examples
Improved share button design
Better social media link previews
Improved SEO and social sharing
Updated sidebar design
Pulmonary Embolism: SHE mnemonic for Virchow triad, smoking added to endothelial injury, removed PERC Rule and Revised Geneva Score
DKA: 5 I's mnemonic with colored bold letters
Quick References section added to dashboard overview

v3.3 -March 25, 2026

Fixed Infective Endocarditis -5 placeholder sections replaced with full clinical content (workup, antibiotics by organism, monitoring, summary)
Fixed Syncope -4 placeholder sections replaced with management by etiology, medications, monitoring, and disposition criteria
Fixed Hospice topic -4 corrupted sections (were showing Tumor Lysis/Vasculitis content) replaced with proper hospice content
Fixed Pericarditis and Aortic Dissection duplicate One Pager placeholders
Critical bug fix for search and navigation
Em dashes removed across the website
Improved search engine visibility
About page stats updated to reflect actual counts

v3.2 -March 25, 2026

SSC 2026 guidelines integrated across sepsis topic -all SSC 2018/2021 references updated
ACS 2025 guidelines added to What's New
NEWS/MEWS/NEWS2 calculators added (replacing qSOFA per SSC 2026)
Clinical calculators organized by rotation -Nephrology, Cardiology, Pulmonology, ICU, GI, General
Media Library -medical movies, documentaries, TV series, and finance books for residents
Gifted Hands: The Ben Carson Story added to Movies
Resources page -recommended books section (Oxford Handbook, Harrison's, Pocket Medicine, ICU Book, Guide to IM Workups)
Resources page -SSC 2026 guidelines added, cleaned up tools and references
Channels & Podcasts -YouTube and podcast icons replace emojis
Recently viewed topics in sidebar
Offline indicator banner
Share button (WhatsApp, email, text, copy link)
Black sidebar redesign with improved contrast
SSC 2026 pimp questions -6 new guideline-specific questions in sepsis topic
11 new SSC 2026 pearls added to Pearl of the Day rotation
Pearl of the Day now starts at random position each page load
SSC 2026 dashboard banner linking to What's New
Clean URL routing -SEO-friendly URLs
Sitemap updated with clean URLs for Google Search Console
Google Analytics tracks individual page/section views
RoundsRx logo click returns to dashboard
Meta description optimized for SSC 2026 search traffic
Focus outline removed on section navigation
Diagnostic Dash temporarily removed (under development)
Google Analytics integration
Smart back button with navigation history
Auto-updates on new deployments
Deployed live at roundsrx.com

v3.1 -March 24, 2026

Smart search -typo-tolerant search across all topics and drugs
41 landmark trials now searchable by name (PARADIGM-HF, DAPA-HF, RALES, etc.)
Search results scroll directly to matching section and highlight the target
HFrEF vs HFpEF side-by-side management comparison with 14 trial citations
STEMI clinical case scenarios with troponin intervals
Clinical case block styling improvements

v3.0 -March 22, 2026

34 clinical worked examples with step-by-step bedside scenarios
263 "Updated Practice" callouts flagging old vs new teaching
792 trial badges -all with hover descriptions
1,775+ drug entries with brand names
21 clinical calculators
New tools: Lab Interpretation Guide, ECG Pattern Guide, Antibiotic Duration Cheat Sheet, IV Fluids Guide, What's New section
70+ stub sections replaced with real disease-specific content
20+ mislabeled sections corrected (copy-paste errors)
Fixed corrupted HTML in asthma, HCM topics
73 abbreviation definitions added across tables

v2.0 -March 21, 2026

Expanded to 146 clinical topics across 15 rotations
657 pimp questions with reveal answers
Collapsible sidebar, dark mode, mobile responsive
SEO optimization, PWA offline support

v1.0 -March 12, 2026

Initial build: 89 topics across 15 rotations
Dashboard, search, dark mode
Offline-capable architecture

Disclaimer

RoundsRx is an educational tool designed to support -not replace -clinical judgment. All content is evidence-based with trial citations, but medicine evolves rapidly. Always verify drug dosing with your pharmacy, confirm guidelines with your institution, and use primary sources (UpToDate, society guidelines, package inserts) for patient care decisions. RoundsRx is not responsible for clinical outcomes.

Credits & Acknowledgments

Built by residents who got tired of flipping between five apps on rounds. Content sourced from major society guidelines (AHA/ACC, KDIGO, IDSA, ATS, AASLD), landmark clinical trials, and UpToDate -then distilled into the format we actually need at 3 AM.

Special thanks to the attendings who pimp relentlessly -you made this necessary.

Contact

Found an error? Have a topic request? Want to contribute? Reach us at RoundsRx@gmail.com. We read every email and prioritize corrections within 24 hours.

Last updated: July 23, 2026 at 1:30 PM