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 268 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
268
Clinical Topics & Tools
1,318
Clinical Alert Flags
Key Features
🔍 Smart Search
Full-text search across every word on the site, all topics, drugs, and 1,878 trial citations. Results highlight and scroll directly to the matching content.
📚 Trial Citations
1,878 trial badges with hover tooltips explaining study design, key findings, and clinical impact.
🧠 Pimp Me Quiz
1,070 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
1,178 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.
Terms of Use
© 2026 RoundsRx. All rights reserved.
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
v6.0 - September 7, 2026
- NEW TOPIC: High-Altitude Illness (AMS, HACE, HAPE). The site had nothing on altitude medicine: no topic, no infographic, no pearls, and zero standalone mentions of HAPE or HACE anywhere in 65,000 lines. The only traces were three incidental references (high altitude as a cause of hypoxemia, acetazolamide for high-altitude sleep apnea, and low FiO2 in the A-a gradient calculator). That left an obvious hole in an environmental-emergencies group that already carried Heat Stroke, Hypothermia & Drowning, Burns and Necrotizing Fasciitis. The new page runs to 8 tabs (Overview, Diagnosis, Management, Prevention, Medications, Special Cases, Rounds, Summary) with 12 pimp questions and 6 trial citations, built on the Wilderness Medical Society 2024 Update rather than the retired 2019 edition.
- The 2024 guideline retires several things older sources still teach, so each is called out explicitly. Salmeterol was removed for HAPE prevention; inhaled budesonide, acetaminophen for prevention and hypoxic tents are now recommended against; acetazolamide is advised against for HAPE treatment; and nifedipine for HAPE was narrowed to cases where descent is impossible AND oxygen is unavailable. Also new in 2024: pre-travel evaluation after COVID-19 when symptoms persist at 2 weeks or ICU care was needed. A recommendation that is merely absent reads as an oversight, so the retirements are tagged rather than silently dropped.
- The two acetazolamide doses get their own warning, because they are the pair most often transposed. Prevention is 125 mg q12h and treatment is 250 mg q12h. The page also explains why going higher is pointless: 250, 500 and 750 mg/day were all effective with an NNT of 3 to 8 and no efficacy gain Low, 2012, and that 250 mg/day IS the 125 mg twice-daily regimen, which is where most of the confusion with older sources comes from.
- Also covered: the 2018 Lake Louise score and why the sleep item was deleted (periodic breathing disrupts sleep in almost everyone at altitude, so scoring it diagnosed AMS in well people), why HAPE must not be diuresed (a permeability leak with a normal wedge pressure in a volume-depleted patient), why ataxia rather than confusion is the HACE alarm, and why a patient must never resume ascent after dexamethasone. Mimics get their own section, including carbon monoxide from a stove in a tent, where pulse oximetry reads falsely normal.
- Mechanism is now its own tab, because a bare protocol was never the point. The page originally stated the pathophysiology only in passing. It now walks the chain explicitly: hypoxia dilates cerebral vessels (blood flow up ~24% within hours), VEGF, nitric oxide and free radicals make the blood-brain barrier leaky, and the result is vasogenic white-matter edema a tight skull cannot buffer (the tight-fit hypothesis, which also explains why the young are more susceptible than older adults with some atrophy). Acetazolamide gets the full four-site account rather than the textbook one: renal bicarbonate wasting, tissue and red-cell CO2 retention, carotid body effects that damp periodic breathing, and mild diuresis. Leaf and Goldfarb's J Appl Physiol review concluded the renal explanation alone is unsatisfactory, and the page says so. A closing table maps each drug onto the step it acts on, which is why acetazolamide is right for prevention and wrong for HACE and HAPE.
- The at-a-glance syndrome table was rebuilt around mechanism and treatment. The Frequency column became Mechanism of Action and Untreated Course became Treatment, and How It Works. Nothing verified was discarded: the incidence figures moved into the onset column, and the mortality facts (coma within 24 h in HACE, 50% in HAPE) were kept inside the treatment cell as the reason the treatment is urgent. The Altitude Bands table was cut as low-yield, with its one load-bearing number, the 2500 m threshold, retained.
- FIXED: four live pages were telling Google not to index them. Search Console reported 146 pages "Crawled, currently not indexed" with a failed validation. Two separate causes. First, the edge function keeps its own hardcoded copy of the title and description maps, and any slug missing from both falls into the unknown-slug branch, which serves the entire 11.6 MB shell with all 284 views and sets
X-Robots-Tag: noindex. Four real, deployed, sitemap-listed pages were in that state, including Outpatient Hypertension, Refeeding Syndrome, Legionnaires’ Disease and the new High-Altitude Illness page. Adding a topic to index.html was never enough; it had to be registered in the edge function too, and nothing enforced that. Now registered, and audit.js gained an edge-function-unregistered check that fails HIGH if any sitemap URL is absent from both maps. The existing view-isolation guard could not catch this, since it samples six URLs and these pages never reach the stripper at all.
- FIXED: the sitemap was telling Google nothing had changed since April. Of the 146 affected URLs, roughly 120 were last crawled on 25 March 2026, months before the August fix that ended the duplicate-content problem. Yet 235 of 285 sitemap entries still declared
lastmod 2026-04-12, so Google had no reason to re-crawl and the validation it ran on 5 September re-checked five-month-old data. Refreshed 247 lastmod dates to reflect the work actually done since, and added the one view that was missing from the sitemap entirely (Legionnaires’ Disease). Verified first that all 285 sitemap URLs map to real views, so nothing dead is being advertised.
- The outpatient hypertension table listed losartan as though it were the ARB class. It is not. Losartan earns its place by being cheap and uniquely uricosuric (it inhibits URAT1 in the proximal tubule, making it the ARB of choice alongside a urate-raising thiazide, and in HTN with gout), but it is also the weakest and shortest-acting agent in the class, with control measurably fading before 24 h. Added valsartan, which is used at least as commonly and is the ARB inside Entresto, with the caution that much of its weak reputation comes from being left at 80 mg when the target is 320 mg VALUE, 2004. Added a third row for the rest of the class, since it is not interchangeable: potency per mg runs candesartan > telmisartan ≈ losartan > irbesartan ≈ valsartan, and the pick follows the comorbidity, with irbesartan for diabetic nephropathy IDNT, 2001 and candesartan where heart failure coexists CHARM, 2003. Also flagged olmesartan sprue-like enteropathy, worth recalling before a celiac workup.
- Asthma reversibility corrected, and a logic error found alongside it. Bronchodilator reversibility is FEV1 or FVC rising by ≥ 12% AND ≥ 200 mL per GINA, and the asthma page carries both thresholds. Checking every statement of it site-wide surfaced a genuine error in the PFT case: non-reversibility was written as "< 12% AND < 200 mL". Reversibility requires BOTH thresholds, so its negation is "< 12% OR < 200 mL". As written, a patient improving 15% but only 150 mL would have failed to be classified as non-reversible. Fixed, and every reversibility statement on the site now agrees.
- Thin sections: first six rebuilt, ranked by inbound internal links. A sweep found 82 sections with under 400 characters of body. None were empty, but many were bare lists that break the "explain the why" rule: "CTA abdomen/pelvis, sensitivity 95%. Lactate, LATE marker" states what to order and nothing about what it means. Rebuilt Acute Pancreatitis (Workup, Medications), Acute Mesenteric Ischemia (Workup, Medications), Anemia (Workup) and ACS (Workup), taking them from 93-281 characters to 1,700-4,000. Three substantive gaps closed along the way: the pancreatitis fluid rate had no indication it comes from WATERFALL or that the aggressive arm caused harm and stopped the trial early; the mesenteric ischemia page never said not to give oral contrast (it obscures the bowel wall you are assessing) nor that a normal lactate cannot rule out; and the ACS workup omitted posterior leads V7-V9, without which a true posterior STEMI is managed as an NSTEMI and misses the cath lab. Also fixed a malformed trial sticker that rendered as "[ACG Guidelines, Defined 2005". 76 thin sections remain, tracked and ranked.
- FIXED: 22 empty tabs across 11 topics that only said "the content is in another tab." A resident opening COPD › Medications got one italic sentence and no drugs. The cause was structural, not editorial: a standard tab set (Overview / Workup / Management / Medications) had been appended to topics that already had their own bespoke tabs (Stepwise Therapy, Treatment, Rotation Protocol, Nodule Workup), creating empty twins. The COPD stub was the clearest tell, since it pointed readers to a "Management" tab that did not exist in that view. Every stub was verified against its siblings before removal, and the bespoke tabs were renamed to the site’s conventional Management, so COPD now reads Overview / Management / Rounds / Summary / One Pager instead of seven tabs with two dead ones.
- Two stubs were NOT deleted, because deleting them would have lost content. Pneumothorax › Workup was the view’s only diagnostic surface, so it was written rather than removed: upright versus supine films and the deep sulcus sign that makes supine the place pneumothoraces get missed, lung ultrasound (sensitivity 0.91, specificity 0.99 against supine radiography, with the lung point 100% specific but only 66% sensitive Lichtenstein, 2000), when CT earns its place, and the BTS 2023 shift to symptom-driven rather than size-driven management. Separately, the obesity stub held the only SCALE citation on the entire site, so that sticker was grafted onto the Liraglutide row before the stub came out.
- audit.js gained Check 9 so this class cannot come back. Check 8 was a hand-maintained list of placeholder phrases, which is exactly why 22 stubs written in wordings it did not list sailed through every green audit. The new check is structural: a section-anchor whose short visible text consists of a pointer to another tab is flagged HIGH regardless of phrasing. It immediately found a 23rd stub a hand-written grep had missed (pneumonia › Medications, phrased "are in the Treatment tab"). It is deliberately not a length threshold, since several genuinely terse sections carry real content and scoring by length reproduces the all-noise failure this file records.
- The Mechanism tab now opens with a flowchart. A prose chain is hard to hold in working memory, so the tab leads with a diagram that makes three things visible at once: one root cause (a pressure problem, not an oxygen-fraction problem), a compensation whose slow step is renal and is therefore the step worth accelerating, and two organ chains that share nothing but the trigger, which is why roughly half of HAPE cases carry no AMS. Each drug is placed under the step it acts on, with oxygen and descent beneath everything because they remove the input rather than blunting a response to it. Built as inline SVG using only the site’s own CSS variables, so it inverts correctly in dark mode and its labels stay searchable, matching the existing BMP and CBC fishbone diagrams.
- The pulmonary vasodilators got a fuller and fairer treatment in HAPE. The first draft listed nifedipine alone for treatment and omitted tadalafil and sildenafil as options entirely, which made the whole drug class read as marginal. It is not: for prevention in a susceptible person these ARE first-line, with randomized evidence behind them. The 2024 ordering for TREATMENT is now stated with its grades: nifedipine when descent is impossible and oxygen or hyperbaric therapy unavailable (strong recommendation, low-quality evidence), then tadalafil or sildenafil only if nifedipine is also unavailable (weak recommendation, low-quality evidence, since no systematic study has tested either for HAPE treatment). That low grade traces to a six-patient uncontrolled series Oelz, 1989, and the page says so rather than implying the drug does not work.
- NEW INFOGRAPHIC #226: High-Altitude Illness. Printable A4 one-pager with QR short link, filling the sheet to 791 pt of the 700 to 800 pt window. Wired into the Emergency Medicine rotation, the EM navigation menu, the Ambulatory grid, the sitemap, and the related-topic graph alongside Hypothermia & Drowning, Heat Stroke, Pulmonary Embolism, Acid-Base and OSA.
- Corrected on re-verification before publishing: a draft of both the page and the sheet put AMS incidence at "25% at 3500 m". That 25% figure actually belongs to Colorado ski-resort altitudes of 2500 to 3000 m, so it was fixed in both places rather than only the one that was noticed first.
- Build stats refreshed and two stale numbers corrected: 268 topics and tools (the About introduction had drifted to 263 while the stats grid said 267), 1,402 pimp questions, 1,866 trial citations (the Key Features tiles had been stuck at 1,853), 1,309 alert flags, 6,466 drug-table entries, 226 infographics. Open Graph image regenerated to match.
v5.9 - August 19, 2026
- Three pocket references were missing from the homepage, one of them unreachable entirely. A link audit found that Insulin Calculator had no internal link anywhere on the site: it existed, had its own URL, sat in the sitemap and the search index, so Google could send a reader there, but nobody browsing could ever find it. Vasopressors & Inotropes and the Glasgow Coma Scale were reachable but buried behind one or two deep links and absent from the Quick Reference grid, which is where people actually look for them. All three are now on the homepage. The vasopressor guide is the one worth flagging: at 17,000 characters of dosing, receptor activity and when-to-switch guidance, it was one of the most substantial references on the site and effectively invisible.
- Layout shift: the last unreserved images now hold their space, and a claim of mine turned out to be wrong. After fixing the infographic thumbnails, a scan suggested roughly 270 more images had no reserved height. Checking properly, that was wrong: the scan read only the image tags and could not see CSS. The 30 book and film covers already carry width:45px; height:67px with object-fit, and the 223 library thumbnails sit in a container that already declares aspect-ratio:520/735. Both were fine all along. The genuine group was 16 portraits in Famous Cases, which render at a fixed 110px width with no height, so until each file decoded the browser reserved zero height and the text reflowed around it mid-read. Their intrinsic ratios run from 0.60 to 1.77, so a single aspect-ratio rule would have distorted most of them; each now carries its own real dimensions, read from the file. That fix initially broke them: width and height attributes are presentational hints, and the inline style overrode the width but not the height, so every portrait rendered 110px wide by its full intrinsic height, badly stretched. Adding height:auto restores proportional scaling while the attributes still supply the ratio. Verified across all 16: each reserves a correctly proportioned box before its bytes arrive. Also checked every referenced image on the site, all 49 exist and are healthy, though three unreferenced corrupt files are sitting in the covers folder.
- 35 landmark trials now open a full evidence card instead of a one-line tooltip. The hover citation is this site's core evidence surface, but only about 200 entries backed 1,851 stickers, so most degraded to just the trial name. A scan ranked every cited trial by how often it appears without a card, and the most-cited were written first, since one entry upgrades every page citing that trial. Added, each verified field-by-field against its primary publication: SOAP II (read honestly, it was NOT a mortality win; norepinephrine became default on the arrhythmia burden of 24.1% vs 12.4% plus the harm signal in cardiogenic shock), TRAPS (stopped early for harm, which is why antiphospholipid syndrome stays a warfarin indication), CHANCE and POINT as a deliberate pair, since CHANCE stopped dual antiplatelet at 21 days with no bleeding penalty while POINT ran to 90 days and bled, which is exactly why guidelines say 21, CRASH-2 (with the timing analysis that matters more than the headline: give tranexamic acid within 3 hours or not at all, because after that it appears to cause harm), SUSTAIN-6 (including the retinopathy signal usually left out), REDUCE-IT (stating the unresolved mineral-oil placebo problem rather than sanding it off), COPE and ICAP, SBP albumin (including the day-3 dose that gets forgotten), SELECT, EXPLORER-HCM, and INTERACT2 (whose primary endpoint did NOT reach significance, a fact routinely misquoted; the case rests on the ordinal analysis plus the absence of harm). A second pass added AUGUSTUS (the factorial design that isolated aspirin as the bleeding culprit, roughly doubling it), COAPT (paired with the note that MITRA-FR tested the same device the same year and was NEGATIVE, and why patient selection explains the split), FOURIER and ODYSSEY OUTCOMES, SPARCL (including the hemorrhagic-stroke signal that matters if the index event was a bleed), de Gans (where the timing is the intervention: dexamethasone before or with the first antibiotic dose, not after), Temel (the group receiving LESS aggressive care lived longer) and GELA. A third pass covered the negatives and near-misses, which are the ones most often misquoted: PROMINENT (lowering triglycerides did NOT reduce events, because apoB never fell, which is the strongest argument for treating apoB rather than the triglyceride number), DETO2X-AMI (retiring routine oxygen in MI without hypoxemia), AID-ICU (haloperidol did not improve the primary endpoint, so antipsychotics control agitation but do not treat delirium), and AFFIRM-AHF, whose primary endpoint narrowly MISSED at p=0.059 despite being routinely cited as positive. Plus REPRIEVE, EPHESUS, DahLIA, EAGLES (which got the boxed warning removed from varenicline) and I-PASS, one of the few interventions ever shown to cut real patient harm rather than a process measure. A final pass cleared the top of the list: BRIDGE (bridging added bleeding without preventing clot, though the trial excluded mechanical valves and recent stroke, so the highest-risk patients still need individual assessment), AVOID (which goes further than DETO2X-AMI: not merely no benefit but larger infarcts on MRI with routine oxygen), AGREE (same efficacy at low-dose colchicine with diarrhea in 23% instead of 77%, which is why hourly dosing to toxicity is obsolete), WATERFALL (stopped early because aggressive fluids in pancreatitis caused overload in one in five without preventing severe disease) and the CTT Collaboration meta-analysis of 170,000 patients behind lower is better. Stickers resolving to a full card rose from 679 to 861, now 49% of all citations, from 238 database entries. More to follow.
- FIXED: 29 pimp answers could never be revealed at all, and two more legacy formats found. Sweeping the remaining topics turned up three further problems. 29 cards across 8 topics carried a typo -
toggle('reveal') instead of toggle('revealed')- so clicking them did nothing and the answer could never be seen. Affected thyroid storm, hypercalcemia, antiphospholipid syndrome, scleroderma renal crisis, ANCA vasculitis, adrenal crisis, rheumatoid arthritis and gout. Separately, two older card formats showed the question and answer together with nothing to reveal: 12 cards in syncope and corticosteroids used a plain Q/A text block, and 12 more in Ebola and CKM split the question and answer into sibling elements so both rendered openly. All 24 were converted to proper tap-to-reveal cards. Two topics had exactly one question each (PMR/giant cell arteritis and hypoparathyroidism), too few to page through, so each was given a full set of 8 verified questions covering the steroid dose that differs between PMR and GCA, why starting steroids does not ruin the temporal artery biopsy, why calcitriol is used rather than ordinary vitamin D, and why the calcium target is deliberately low-normal. Final state, verified by clicking every card on the site: 222 of 222 topics render a carousel, and all 1,376 answers reveal correctly.
- FIXED: 233 pimp questions across 49 OTHER topics were never reaching a carousel either. Converting the 17 flat-list topics prompted a check of the whole site, which found a second and larger problem hiding underneath. The carousel is built at page load by a function that finds consecutive reveal cards and wraps them, but it only inspected one kind of container. 49 topics place their cards directly inside the section wrapper with no inner content block, so the function never looked there and 233 questions rendered as a loose stack -answers hidden, no way to page between them, no dots or arrows. Affected topics included anticoagulation, atrial fibrillation, CKD, inpatient diabetes, hypothyroidism, Graves, myxedema coma, pheochromocytoma, Cushing, multiple myeloma, leukemia and around 38 more. The cards were never the problem: they sat perfectly consecutive, in the right order, correctly written. The fix is one line -the initializer now scans both container types- which repaired all 49 at once and immunizes any topic written that way in future. Two remaining views are untouched on purpose, since a single question needs no carousel. One pocket-card page held its questions in an unclassed layout wrapper and was given the standard class, which is margin-only and changes nothing visually. Verified across every view on the site that contains pimp questions: 218 of 220 now render a carousel, the other two being the single-card pages, with 1,348 cards in 222 carousels and tap-to-reveal confirmed working on all 218.
- FIXED: pimp questions on 17 topics were a flat list instead of the interactive carousel. Every topic built recently rendered its pimp questions as a plain bulleted list with the answer sitting in the open next to the question, so there was nothing to test yourself against -you read the answer whether you wanted it or not. The rest of the site uses tap-to-reveal cards in a swipeable carousel, and that is the format these should have used. All 188 questions across 17 topics were converted (bronchiectasis, opioid and alcohol use disorder, hypogonadism, pressure injuries, menopause, insomnia, lymphadenopathy, Lyme, deprescribing, urinary incontinence, frailty, contraception, chronic cough, BPH, malaria and central fever). Worth recording why it happened: the carousel is not written by hand. A function at page load finds consecutive reveal cards and wraps them into a carousel automatically, which is why 125 topics look like loose cards in the source and render as carousels anyway. Writing the markup by hand was never the answer; emitting the right element was. The conversion also exposed 12 answers that were too short, between 36 and 79 characters, which the audit only started flagging once they were in the checked element. None were truncated, but several had dropped the reasoning, so each was expanded with the actual why rather than padded -for example, why a normal chest radiograph does not exclude bronchiectasis, and why physical cooling works in central fever when acetaminophen does not.
- NEW TOPIC: Central Fever & Paroxysmal Sympathetic Hyperactivity, with printable one-pager #224. A total blind spot -central fever, neurogenic fever, paroxysmal sympathetic hyperactivity and sympathetic storming all had zero mentions- for two things the injured brain does that routinely get treated as sepsis for three weeks. Fever is not a bystander here: after SAH, TBI and stroke it is independently associated with worse function and mortality even after adjusting for injury severity, because a damaged brain has no metabolic reserve, so normothermia is a treatment goal rather than a comfort measure. Both diagnoses are diagnoses of exclusion, and the expensive error runs in both directions: calling it central on day 2 and missing ventriculitis, or calling it sepsis for weeks and never treating the storm. For central fever the page gives the four features from Hocker (2013) that together predict it with a probability of 0.90 -negative cultures, no infiltrate on chest radiograph, a diagnosis of SAH, IVH or tumor, and onset within 72 hours- and explains what they are actually for, which is permission to stop antibiotics in a patient who is still febrile. It also answers the question residents rarely get told: why acetaminophen barely works. Ordinary fever is prostaglandin-mediated and antipyretics lower the PGE2-driven set point, but central fever is direct disruption of hypothalamic thermoregulation, so there is little prostaglandin signal to interrupt -a fever that shrugs off acetaminophen is a clue, not a dosing problem, and physical cooling is the mainstay precisely because it bypasses that pathway. For storming, it covers the Baguley (2014) consensus that replaced more than 31 competing eponyms, the PSH-AM and its six cardinal features, and the single most useful discriminator: if the temperature rises alone it is central, and if everything rises together in paroxysms it is storming. Treatment is framed as three separate jobs -abort with morphine, prevent with propranolol (chosen because it is lipophilic and crosses the blood-brain barrier) and gabapentin, and remove the triggers, which is the underrated half: before adding a fifth drug, check the bladder and the bowels. And the evidence is stated honestly rather than dressed up: there are no randomized trials for either condition, so add one agent at a time and titrate to an observed effect. Filed under ICU, which moves from 27 to 28 topics.
- FIXED: myxedema coma appeared twice in Endocrinology. The rotation grid offered "Thyroid Storm & Myxedema" and, three rows later, "Myxedema Coma" -two cards for overlapping content, with no way to tell which was authoritative. Behind them, the thyroid storm page carried a Myxedema Coma tab of about 3,000 characters while the standalone page ran to 23,000 characters across seven tabs. The standalone page is the better home, and it was verified to already contain every safety point the shorter version made, including hydrocortisone before levothyroxine and passive rewarming only, before anything was removed. The thyroid storm page is now titled just Thyroid Storm, and its duplicate tab is replaced by a "vs Myxedema Coma" comparison, matching how the SIADH page already handles its "vs DI & CSW" differential. That tab now earns its place instead of repeating a page: the two emergencies are mirror images, so it contrasts them line by line (hyperthermia vs hypothermia below 35°C that a standard thermometer may not even register, tachycardia vs bradycardia, agitation vs coma, tachypnea vs CO₂ retention) and states the three things they share -both are clinical diagnoses, both are usually precipitated by infection, and both get stress-dose hydrocortisone- alongside the one that is opposite, since storm is cooled while myxedema coma is rewarmed passively only or vasodilation causes cardiovascular collapse. Both topics keep sharing printable sheet #84, which covers both emergencies by design.
- What's New now carries exact dates, and the timeline is in the right order. Most entries showed only a year, and older ones only "2023" or "2020", which is not much use for judging how current a recommendation is. 24 entries were researched against their primary publication and given full dates, so you can see that CLOVERS landed February 9, 2023 and SELECT November 11, 2023 rather than both reading "2023". Adding real dates exposed a second problem: the timeline was out of order in every one of its four sections -SELECT sat below CLOVERS despite being nine months later, EMPA-KIDNEY below DELIVER, and the whole 2020 group ran backwards. Each section is now sorted newest-first, verified across all 31 entries with no content lost. Two entries were deliberately left without a day, because inventing one would be worse than the gap: NCCN guidelines are continuously versioned rather than released on a date, and the GOLD 2026 report has no single verifiable release day. One quirk worth explaining rather than hiding: the ADA and GOLD 2026 editions were actually published in late 2025 (December 8 and November), so they are tagged "2026 EDITION" and kept with the other 2026 guidelines, which is how clinicians refer to them.
- CORRECTED: the CONFIRM trial card overstated terlipressin, and Chronic Cough shipped with no trial citation. The deploy-prep re-verification caught both. CONFIRM was marked green and "Positive" on the strength of its primary endpoint (verified hepatorenal syndrome reversal, 32% vs 17%), with the harms compressed to "more respiratory adverse events." The primary endpoint is real and it won terlipressin its FDA approval, but the card omitted the part that changes a bedside decision: there was no survival benefit, and by day 90 death occurred in 51% on terlipressin versus 45% on placebo, with an excess of early respiratory failure contributing. That is a mixed result, not a clean win, and the card now says so and is re-graded amber. Chronic Cough carried zero hover citations, which is wrong for a page making an efficacy claim: the gefapixant discussion now cites COUGH-1 and COUGH-2, 2022, including the fact that the 45 mg dose met the primary endpoint while the 15 mg dose failed it in both trials, which is useful context for why regulators reached different conclusions.
- FIXED: the One Pager tab did not scroll to the infographic. A separate cause from the tab-offset fix below, and it needed two repairs rather than one. First, the embedded sheet thumbnail is lazy-loaded and declared no dimensions, so until it decoded its height was zero. That collapsed the whole One Pager section, and since it is the last section on the page, the click computed its target against a document 736px shorter than the real one, landed at what looked like the bottom, and only then did the image load, expand and push the infographic below the fold. Every sheet renders to exactly 520x736, so that box is now reserved up front with a fixed aspect ratio, which also removes the layout shift on all 231 pages that embed a sheet.
That alone was not enough, which is the more interesting half. A smooth scroll animates toward a pixel value fixed at the moment you click, and the journey itself keeps moving the layout: there are 505 lazy elements sitewide, images decode as they approach the viewport, the bar gains its title row when it sticks, and the browser's scroll anchoring shifts the position again to compensate. Whether anchoring absorbs a given shift is not predictable, so no smarter up-front calculation can fix it. The target is now re-checked after the motion stops, on a schedule out to about 1.2 seconds, snapping back whenever the section has drifted, and standing down if you scroll or click elsewhere so it never fights you. Confirmed by injecting a 300px shift immediately after a landing: the page repairs itself back to the correct position. All 1,623 tab targets across 237 topic pages verified, including all 211 One Pager tabs, each landing with the infographic on screen directly under the bar.
- FIXED: clicking a tab scrolled the section heading BEHIND the sticky bar. Every tab on every topic put the section you asked for underneath the bar you clicked it on, so you landed mid-paragraph with the heading invisible and had to scroll back up. The scroll target subtracted a hardcoded 52px for the bar, but real bars are 44 to 64px before they stick and gain about 32px when the compact title row appears, so 76 to 96px in practice depending on how many tabs the topic carries. That left the heading 24px behind the bar on a five-tab topic and 44px on a six-tab one, which is why it felt worse on some topics than others. The offset is now measured rather than assumed. One subtlety made the first attempt wrong: measuring the bar in its current unstuck state looks self-correcting, since the bar gains 32px and the section below flows down by the same 32px, but Chrome's scroll anchoring absorbs that shift to keep the view visually stable, so the section stays put and the heading still lands behind the taller bar. It now measures the bar at its stuck height. The scroll-spy that highlights the current tab shared the same hardcoded assumption and was promoting the next tab while its section was still hidden, so it tracks the real height too. Verified by driving the actual click handler for all 1,623 tab targets across all 237 topic pages: every section now lands just below the bar, none behind it.
- FIXED: trial tooltips that silently showed the short version, and a sticky tab bar that announced itself early. 86 trial stickers across the site were quietly failing to reach their full trial card. The tooltip looks up a trial by matching the badge text against the trial database key, and it stripped separators from the badge word but not from the key, so a hyphenated name could never match an underscored key: RE-LY became "rely" and was tested against "re_ly_2009", which does not contain it. Same for ROCKET-AF, MERIT-HF, CIBIS-II, DAPA-HF, EMPEROR-Reduced, SUP-ICU, EMPA-KIDNEY, FIDELIO-DKD, ANDROMEDA-SHOCK and dozens more. Every one fell back to the one-line summary while a full card with population, intervention and primary endpoint sat unused. Matching now happens on token boundaries rather than raw substrings, which fixes those without the obvious over-correction: simply stripping separators from both sides lets a word match across boundaries, so DASH matched ANDROMEDA_SHOCK_2019 (an-drome-dash-ock) and PATHWAY-2 matched the wrong trial entirely. The badge year is now also used to disambiguate same-named trials, so SHARP, 2011 reaches the CKD trial rather than the 2008 one and SURMOUNT, 2022 reaches SURMOUNT-1. Six genuinely wrong matches were removed in the process (Rowe was matching PROWESS-SHOCK, RE-COVER was matching RECOVERY, COPE was matching COPERNICUS). Separately, the sticky tab bar decided it was "stuck" by watching the hero banner rather than itself. Those are the same thing only when the bar sits directly under the hero; on the Lab Interpretation page, which places an 824px block of fishbone diagrams between them, the compact title row appeared while the bar was still 243px down the page and not pinned at all. It now keys off its own pinned position. Verified across all 237 topic pages with tabs: every one pins correctly, and none reports itself stuck before it is. Also added the four landmark DOAC trials as proper hover citations (RE-LY, ROCKET AF, ARISTOTLE, ENGAGE AF-TIMI 48) where they had been named in plain text, and noted on the ENGAGE card that edoxaban should not be used for atrial fibrillation when CrCl is above 95, where its efficacy falls off.
- NEW TOPIC: Malaria, with printable one-pager #223. A genuine gap -artesunate appeared exactly twice on the whole site- for a disease that can take a walking, talking patient to dead inside 24 hours. Three things carry it. Ask about travel in every febrile patient, because malaria is missed by not thinking of it rather than by any difficulty in making the diagnosis, and it is routinely called influenza or gastroenteritis; note that the classic periodic fever is usually absent in non-immune travelers, and that taking prophylaxis does not exclude it. One negative smear excludes nothing -parasitemia fluctuates through the replication cycle, so it takes thick and thin films every 12 to 24 hours and three negative sets, with thick for sensitivity and thin for species and percent parasitemia. And NEW 2026 CDC extended artemether-lumefantrine from 3 days to 5 (10 doses) for uncomplicated falciparum, driven by spreading artemisinin partial resistance, declining lumefantrine effectiveness, and the fact that US patients are non-immune travelers rather than the semi-immune populations in which 3 days was established -so the regimen most people would write from memory is now wrong. The page also covers the severity criteria, including the one that catches people out: a parasitemia of 5% or more is severe malaria however well the patient looks. IV artesunate 2.4 mg/kg at 0, 12 and 24 hours, stickered with SEAQUAMAT (mortality 22% to 15% in adults, stopped early) and AQUAMAT (10.9% to 8.5% in 5,425 African children), plus the two things that follow it: artesunate can never be the whole treatment because its half-life is too short, and post-artesunate delayed hemolysis shows up 1 to 3 weeks later, so check a hemoglobin weekly for about 4 weeks. Then radical cure for vivax and ovale with mandatory quantitative G6PD first, why it is contraindicated in pregnancy, the two ways a rapid antigen test misleads you (hrp2/hrp3 deletions, and staying positive for weeks after cure), and the fact that exchange transfusion is no longer recommended. Filed under Infectious Disease, which moves from 24 to 25 topics.
- NEW TOPIC: BPH and Lower Urinary Tract Symptoms, with printable one-pager #222. The 2026 AUA guideline landed while this was being written -it replaces the 2023 version, splits into three parts (presentation and evaluation, medical management, procedural and surgical management) and carries 62 recommendations. Two combinations that were previously unsupported now are: daily low-dose tadalafil added to an alpha-blocker or to finasteride, and an antimuscarinic added to an alpha-blocker for storage-predominant symptoms, with a low risk of retention. The guideline also states plainly that urinary symptoms in an older man often come from several causes at once rather than from prostate enlargement alone, which is the error the page is built around. Three things carry it. Prove it is the prostate before treating the prostate: nocturnal polyuria, heart failure, sleep apnea, diabetes, diuretic timing, urethral stricture, neurogenic bladder, infection, bladder stone and bladder cancer all present this way, and a three-day frequency-volume chart separates most of them at no cost. Say how long the drug takes out loud, because alpha-blockers work in days while 5-alpha reductase inhibitors take 6 to 12 months, and the man not told this abandons the 5-ARI in week four. And a 5-ARI halves the PSA, so the measured value must be doubled -a man on finasteride with a PSA of 2.5 has an effective PSA of about 5, which is how a cancer goes unnoticed for years. The page also covers the drug to stop before adding one (anticholinergics, alpha-agonist decongestants, opioids), intraoperative floppy iris syndrome and why stopping the alpha-blocker before cataract surgery does not reliably prevent it, the absolute surgical indications, the procedural menu from TURP through enucleation, UroLift, Rezum and Aquablation, and acute retention including the fact that gradual bladder decompression is a myth and that post-obstructive diuresis must be watched for. Evidence is stickered throughout: MTOPS (combination cut clinical progression 66% versus 39% for doxazosin and 34% for finasteride), CombAT, the VA Cooperative Study showing finasteride was no better than placebo in small glands, PCPT with an honest account of the high-grade cancer signal, L.I.F.T. and WATER. Filed under Ambulatory, which moves from 44 to 45 topics.
- NEW TOPIC: Chronic Cough, with printable one-pager #221. A complete blind spot -upper airway cough syndrome, cough-variant asthma, eosinophilic bronchitis, ACE inhibitor cough and cough hypersensitivity all had zero mentions -and one of the commonest reasons anyone comes to clinic. Three things carry it. Stop the ACE inhibitor before investigating anything, and know the three features that make it easy to miss: onset ranges from hours after the first dose to months into therapy, so long-standing use does not exclude it; it is a class effect, so switch to an ARB rather than another ACE inhibitor; and resolution usually takes 1 to 4 weeks but can linger up to about 3 months, which means a one-week trial off the drug produces a false negative. Everyone gets a chest radiograph. And the big three coexist -upper airway cough syndrome, asthma including the cough-variant form, and reflux- so a partial response means a second cause is also present, not that the first diagnosis was wrong: add rather than substitute. The page carries a step-by-step sequence with the duration each trial actually needs, because a reflux trial abandoned at four weeks instead of eight to twelve is the single commonest way a treatable cough gets labeled refractory. Also the traps: cough-variant asthma often has normal spirometry, reflux frequently causes cough with no heartburn at all, upper airway cough syndrome can be entirely silent, and non-asthmatic eosinophilic bronchitis has normal spirometry and normal bronchoprovocation yet responds to inhaled steroids. Refractory cough is reframed as a hypersensitivity syndrome treated with speech therapy and neuromodulators, and the page states the regulatory position on gefapixant precisely: approved in Japan, Switzerland and the EU, but rejected by the FDA for insufficient evidence of effectiveness rather than safety, so it is not available in the US. Filed under Ambulatory, which moves from 43 to 44 topics.
- NEW TOPIC: Contraception, with printable one-pager #220. The case for putting this on a general medicine site is quantitative: "teratogen" appears 56 times across the library while contraception had no page at all. Internists start methotrexate, ACE inhibitors and ARBs, warfarin, valproate, topiramate, mycophenolate and isotretinoin routinely, frequently without the conversation, so the page opens by making that the prescriber's responsibility -asked before starting, documented, and revisited at every renewal, because a patient can begin a drug safely and conceive two years later on the same prescription. Two ideas organize the rest. Effectiveness is really about user dependence: the under-1% tier exists because nothing in it depends on remembering anything, which is why typical and perfect use are nearly identical there while the pill's gap between them is the whole story. And eligibility is settled by the US MEC 2024 lookup table rather than instinct, which tends to be either needlessly restrictive or dangerously permissive. The page lists the Category 4 conditions a general internist actually meets -led by migraine with aura at any age, the one most often missed, where the concern is ischemic stroke and the fix is asking specifically about aura rather than accepting "migraines". Then the point most clinicians miss: every one of those contraindications is to ESTROGEN, not to contraception. Progestin-only methods and both IUDs remain available in migraine with aura, in smokers over 35, after venous thromboembolism and in most cardiovascular disease, and the copper IUD is hormone-free entirely -so "she can't take the pill" is almost never "she can't have contraception", yet patients are routinely left with nothing. Also covers the interactions that genuinely cause failure (rifamycins and enzyme-inducing anticonvulsants, and the fact that most other antibiotics do not, contrary to belief), the bidirectional lamotrigine problem, why the copper IUD is the most effective and most under-offered emergency contraception, and that no pelvic exam, cervical screening or routine labs are needed to start -those are access barriers without safety benefit. Filed under Ambulatory, which moves from 42 to 43 topics.
- NEW TOPIC: Frailty, with printable one-pager #219. Another genuine blind spot -Clinical Frailty Scale, gait speed, grip strength and comprehensive geriatric assessment all had zero mentions anywhere on the site. The page insists on three distinctions that get collapsed in practice: frailty is not age, not multimorbidity and not disability. Plenty of 85-year-olds are robust and some 65-year-olds are frail; a patient can carry five diagnoses with good reserve or one with none; and disability is established functional loss whereas frailty is the vulnerability that predicts it. Treating them as synonyms is exactly what produces decisions made on the birth date, when frailty actually predicts mortality, delirium, falls, length of stay and postoperative complications more accurately than chronological age. On measurement, the page gives the test characteristics rather than just the cutoff: gait speed of 0.8 m/s or slower is roughly 99% sensitive but only about 68% specific, so a normal speed effectively rules frailty out while a slow one is a prompt for assessment rather than a diagnosis -plenty of slow walkers are slow for orthopedic or pain reasons. It also anchors the Clinical Frailty Scale 1 to 9 with what each band looks like in practice, since a judgment-based scale gets scored inconsistently without anchors, and warns not to score during acute illness because that measures the illness rather than the reserve. Two things carry the management half. Frailty is dynamic, not a one-way trajectory or a terminal label, and the pre-frail are the most reversible group of all -so treating a score as a prognosis to document rather than a target to treat is the commonest misuse of these tools. And progressive resistance training is the intervention with the best evidence by a clear margin, working in the very old and already frail, which is precisely the group told to take it easy; it needs prescribing specifically, because "stay active" reliably achieves nothing. The page closes by insisting frailty must not become rationing: frail patients still benefit from anticoagulation, treatment of infection and appropriate surgery. It modifies the plan; it does not cancel it. Filed under Ambulatory, which moves from 41 to 42 topics.
- NEW TOPIC: Urinary Incontinence, with printable one-pager #218. A condition patients almost never raise and clinicians almost never ask about, which then goes untreated for years while quietly driving the falls, isolation and nursing home placement that get attributed to something else. The page is organized around one procedural rule and one classification. Measure a post-void residual before prescribing anything for urgency -this is the single test that prevents the classic error, because overflow incontinence presents as urgency and frequency, and an antimuscarinic given for presumed overactive bladder precipitates frank retention. And classify by how the leak happens: stress on cough or lift, urge with sudden compelling urgency, overflow with dribbling and incomplete emptying, functional where the bladder works but the patient cannot get there. Also carries DIAPPERS for the reversible causes, several of which are fixed in a single visit, with the note that much new-onset incontinence in older adults is drug- or constipation-related rather than urologic -including the free intervention of moving an evening diuretic to the morning, which converts nocturia and night-time falls back into a daytime nuisance. On treatment: behavioral therapy is first-line for both main types, with supervised pelvic floor training far outperforming a leaflet since most patients contract the wrong muscles; beta-3 agonists are preferred over antimuscarinics in older adults because they avoid the anticholinergic burden entirely; and there is no FDA-approved drug for stress incontinence in the United States, so a pure-stress patient on a "bladder drug" is probably taking an antimuscarinic that will not help. Plus two ward errors -a catheter is not a treatment for incontinence, and nocturia is its own problem with causes outside the bladder. On the antimuscarinic-dementia question the page states the tension honestly rather than picking a side: large cohorts report higher incidence than beta-3 agonists while a very large recent database analysis found none, so that is unsettled, but the immediate anticholinergic harm is not. Filed under Ambulatory, which moves from 40 to 41 topics.
- CORRECTION: the SAMSON statin-intolerance figure was being stated three incompatible ways, two of them wrong. Adding trial citations surfaced it. SAMSON is an n-of-1 crossover in 60 patients who had stopped statins, running four months each of statin, placebo and no tablet, and it measured symptom intensity: 8.0 with no tablet, 15.4 on placebo, 16.3 on statin, with no significant difference between placebo and statin. So the correct statement is that about 90% of the symptom burden induced by taking a tablet was reproduced by placebo -a ratio of symptom intensity. The site said that correctly in two places, but elsewhere rendered it as "90% rechallenge tolerance" and "90% of statin-intolerant patients tolerate the same statin on blinded rechallenge", which are patient-level claims the trial never made. The actual patient-level result is that roughly half of participants successfully restarted a statin. That distinction matters at the bedside, because promising a patient a 90% chance of tolerating rechallenge sets an expectation the evidence does not support and makes the clinician look wrong when it fails. All five occurrences were corrected, including a clinical pearl and two hover tooltips, and the tooltips now carry the actual symptom-intensity numbers. Also added verified citations for ESETT (status epilepticus: levetiracetam, fosphenytoin and valproate equally effective, roughly 46% seizure cessation each) and PEITHO (intermediate-risk PE: thrombolysis cut hemodynamic decompensation 1.6% vs 5.0% but tripled major bleeding to 11.5% vs 2.4%).
- NEW TOPIC: Deprescribing & Polypharmacy, with printable one-pager #217. Two concepts that carry this entire subject had zero mentions anywhere on the site before now. The prescribing cascade is the mechanism behind much avoidable polypharmacy and is invisible unless you look for it: a drug's adverse effect gets misread as a new disease and treated with a second drug. A calcium channel blocker causes ankle edema, which is treated with a diuretic. Metoclopramide causes parkinsonism, which is treated with levodopa. A cholinesterase inhibitor causes urinary urgency, which is treated with an anticholinergic that then worsens the very cognition the first drug was for. The habit that prevents all of it is asking, of every new symptom, whether a drug could be causing it. And time to benefit is what makes deprescribing defensible rather than arbitrary: preventive drugs take years to help while their harms start immediately, so when remaining life expectancy is shorter than that horizon, the drug is burden without realistic prospect of the outcome it was prescribed for. The page deliberately also covers the opposite error, since deprescribing is not only subtraction -START exists alongside STOPP because omitted treatment is as common as inappropriate treatment, with anticoagulation in atrial fibrillation withheld over overstated fall risk the classic example. Plus AGS Beers 2023 and STOPP/START version 3 framed as prompts rather than prohibitions, why anticholinergic burden must be totaled across the whole list including the over-the-counter drugs patients do not report as medications, the boxed warning on antipsychotics in dementia, which drugs must never be stopped abruptly, how to actually run a taper, what changes near the end of life, and the phrasing that makes the conversation land. Filed under Ambulatory, which moves from 39 to 40 topics.
- NEW TOPIC: Lyme Disease, with printable one-pager #216. A disease misdiagnosed in both directions, and the page is built on that symmetry. Erythema migrans is a clinical diagnosis that should be treated on sight -guidance is explicit that serology should not be sent, because antibodies take weeks and a negative result at that stage is falsely reassuring while treatment waits. The rash itself is also widely misremembered: most lesions are uniformly red and only a minority show the classic bull's-eye, so waiting for a target lesion misses the majority. At the opposite extreme, patients with genuine persisting symptoms after treatment are given months of antibiotics: those symptoms are real, but Klempner, 2001 found 90 days of antibiotics no better than placebo and PLEASE, 2016 found longer therapy no better than shorter, while prolonged intravenous access carries real line infection, thrombosis and sepsis risk. The page also carries the three criteria that together define a high-risk tick bite (identified Ixodes species, highly endemic area, and attachment of at least 36 hours -missing any one means no prophylaxis), single-dose doxycycline within 72 hours, short treatment courses recommended explicitly over longer ones, and Lyme carditis, where AV block can progress to complete within hours yet is almost always reversible. Plus why serology cannot be a test of cure, since antibodies persist for years, and a differential for the other tick-borne illnesses including the reminder that doxycycline does not treat babesiosis. Filed under Infectious Disease, which moves from 23 to 24 topics.
- FIX: the QR generator now verifies its own output, closing a defect that would have silently broken sheets on the next re-render. Building the Lyme sheet, QR verification failed outright. The image was a structurally valid QR -a freshly generated one for the same URL failed identically- and the fault was a blind spot in OpenCV's detector for the specific version-2, error-correction-M pattern that URL happens to produce. Every other version and correction level decoded it. Because the project's own
verify-qr.py uses OpenCV, such a code fails our verification, and shipping an unverifiable QR on a sheet whose whole purpose is being scanned is not acceptable. The fix went into the generator rather than the one file, since hand-patching a PNG is overwritten on the next run: gen-qr.py now decodes every code it produces and steps the minimum version up until it succeeds, keeping error correction at M for print robustness, and aborts loudly if no variant works. That self-check flagged four further sheets -airway RSI, lower GI bleed, inpatient diabetes and hypothyroidism- whose regenerated codes were also undecodable. Their published PDFs were checked directly and decode correctly, so nothing in the wild was broken; the exposure was prospective, in that re-rendering any of them would have quietly produced a sheet with an unscannable code. All five were regenerated and re-rendered, and the library verifies at 216 of 216.
- NEW TOPIC: Lymphadenopathy Workup, with printable one-pager #215. A classic "approach to" topic the site referenced 34 times without ever explaining. The organizing insight is that the most useful discriminator is location, not size or tenderness. A supraclavicular node carries roughly a 90% malignancy risk over age 40 and about 25% under it, making it the one node that is never observed regardless of size, tenderness or duration, and side narrows it further: the left (Virchow) drains the abdomen via the thoracic duct while the right reflects mediastinum, lung and esophagus, so the examination goes to a different body cavity depending on which side it is. Size thresholds are site-specific in both directions -an epitrochlear node above 0.5 cm is always abnormal and easily skipped, while inguinal nodes up to 1.5 to 2 cm are commonly normal and are the most over-investigated site. The page carries a regional drainage map so the reader knows what territory to examine, the benign-versus-worrying character features (soft, mobile and tender against hard, fixed, matted and painless; stony-hard suggesting carcinoma and rubbery suggesting lymphoma), the drug causes that occasionally end a workup, and clear criteria for when a 3 to 4 week observation period is and is not acceptable. Two procedural points get their own warnings: excisional biopsy rather than fine-needle aspiration whenever lymphoma is possible, because classification requires tissue architecture together with immunophenotyping and a "reactive" FNA does not exclude lymphoma; and no empiric corticosteroids before a diagnosis, since they are lympholytic, can transiently shrink a lymphoma and falsely reassure, and can obscure the histology enough to make the eventual biopsy uninterpretable. Filed under Ambulatory, which moves from 38 to 39 topics.
- NEW TOPIC: Chronic Insomnia, with printable one-pager #214. A genuine blind spot: "CBT-I" appeared nowhere on the site, and there was no coverage of Z-drug class risks or the orexin antagonists. Two things practice gets backwards anchor the page. Cognitive behavioral therapy for insomnia is first-line by ACP guideline, not medication, and its advantage is durability -hypnotics work while taken, CBT-I changes the behaviors sustaining the insomnia so benefit persists after treatment ends. Notably, guidance suggests against adding a drug to CBT-I rather than using CBT-I alone, so the instinct to do both at once is not supported. Meanwhile sleep hygiene, the thing almost every patient is handed, carries a recommendation AGAINST use as a single-component therapy because it lacks efficacy on its own. Offering a leaflet and then reaching for a hypnotic when it fails is the commonest sequence in practice, and it skips the best-evidenced treatment entirely. The page also carries sleep restriction as the active ingredient with the sleep-efficiency arithmetic that turns it into an actual protocol, the 2019 FDA boxed warning on zolpidem, eszopiclone and zaleplon for complex sleep behaviors -including the two details prescribers miss, that events have occurred after a single lowest-recommended dose and that a prior episode is now a contraindication- and why obstructive sleep apnea must be screened before any sedative, since hypnotics worsen it. Plus a ward-specific section, since that is where residents actually write the order: an inpatient hypnotic is a delirium risk and is frequently continued at discharge into a long-term prescription nobody intended. Also that "secondary insomnia" is an outdated idea -comorbid insomnia is treated in its own right and concurrently, and treating it improves the comorbidity too. Filed under Ambulatory, which moves from 37 to 38 topics.
- NEW TOPIC: Menopause & Hormone Therapy, with printable one-pager #213. Chosen from a fresh gap analysis rather than the old backlog, and built around what is probably the most consequential misreading of a trial in modern medicine. A generation learned that hormone therapy causes breast cancer and heart attacks from a study whose mean participant was about 63 and often more than a decade past menopause, because WHI was designed to test chronic-disease prevention in older women, not symptom relief in the woman actually asking for help. Three things get missed and each one changes the decision. There were two trials and they disagreed: the estrogen-alone arm in women with prior hysterectomy showed no increase in breast cancer, and with longer follow-up a significantly lower risk than placebo, implicating the progestogen rather than estrogen. Age at initiation flips the answer: women randomized at 50 to 59 had favorable outcomes including lower all-cause mortality, so the page teaches asking "how old is she and how long since her last period" before "are the symptoms bad enough to justify the risk." And the correction has a limit that is stated just as firmly: hormone therapy still is not given to prevent cardiovascular disease or dementia, and overcorrecting the other way is its own error. Also carries two situations that invert the usual calculus -premature menopause and primary ovarian insufficiency, where these women are replacing what an age-matched woman still has and withholding therapy is the mistake, and the fact that menopausal hormone therapy is not contraception while ovulation continues erratically through perimenopause. Plus why an FSH is the wrong test over 45, why the genitourinary syndrome is progressive and needs vaginal estrogen in its own right, the CYP2D6 interaction that rules out paroxetine with tamoxifen, and fezolinetant's boxed warning for liver injury added in December 2024 with its specific monitoring schedule. Filed under Ambulatory, which moves from 36 to 37 topics.
- Thyroid-in-pregnancy content flagged as citing a retired guideline. Acting on a standing open finding, the thyroid pages were checked against the ATA 2026 guidelines for thyroid disease in preconception, pregnancy and postpartum, which replace the 2017 edition. The hypothyroidism page attributes its pregnancy figures to "ATA, 2017" in four places, covering the TSH targets (< 2.5 first trimester, < 3.0 later), the 25-30% levothyroxine dose increase, and the monitoring intervals -exactly the kind of numbers a guideline revision moves, since the reported 2026 direction is a more conservative, individualized approach that pulls back from treating subclinical disease where benefit was not shown. The numbers were deliberately NOT changed. Rewriting specific obstetric targets from news summaries and society announcements is precisely what this project forbids, and the exact recommendations require the journal full text. Instead the section now carries a prominent warning that its source guideline has been superseded and that the figures must be verified against the 2026 document before being applied to a pregnant patient. Flagging a retired citation is safer than leaving it looking current, and a page that admits its own staleness is more useful than one that quietly asserts it. One reassurance from the check: the Graves page already uses TRAb to predict relapse before stopping antithyroid drugs and to screen in the third trimester for neonatal hyperthyroidism, which matches the direction the 2026 guideline emphasizes.
- Trial-citation backfill completed across the new topics. Sixteen hover citations now sit on nine of this cycle's pages, each verified field-by-field against the primary publication before being added. Beyond the addiction and bronchiectasis trials below: HORIZON-RFT and ARCH on osteoporosis, COMPASS on peripheral artery disease, MAESTRO-NASH on MASLD, CLARITY-AD and TRAILBLAZER-ALZ 2 on dementia, STAR*D on depression, ORATORIO on multiple sclerosis, and AVOD with DIABOLO on diverticulitis. Several were placed specifically to keep a claim honest rather than to decorate it. The anti-amyloid citations sit on the "set expectations honestly" line because the numbers make that argument better than any adjective: lecanemab's 27% slowing is about half a point on an 18-point scale, against ARIA in a fifth to a quarter of treated patients. ORATORIO is labelled a modest slowing rather than arrest (24% relative reduction). The diverticulitis pair now notes that both trials showed non-significantly higher complication and surgery rates without antibiotics, so they exclude a large difference rather than proving equivalence. And the STAR*D citation flags that its widely-quoted 67% cumulative remission figure is contested by later reanalyses, while the step-wise rates it does cite (about 37%, then 31%, 14%, 13%) stand. The backfill then stopped deliberately. The twelve remaining new pages carry no anonymous trial claims at all: they are diagnostic, staging or guideline-driven topics, and figures like ">95% hepatitis C cure" are pooled across many regimens rather than owned by one trial. Forcing citations onto them would misrepresent the evidence, which is exactly what the new rule forbids.
- Trial citations added to the new topics, and the rule written down. The 23 topics built over this cycle had shipped with no hover trial citations at all while the rest of the site carries over 1,800 of them, which made genuinely evidence-based pages read as unsourced next to their neighbors. The specific failure was writing "a randomized trial found..." without naming the trial, which is an anonymous citation and exactly what the hover sticker exists to prevent. Six were added after verifying every field against the primary publication: O'Donnell 1998 for the dornase alfa harm signal in non-CF bronchiectasis (349 adults, 24 weeks, more exacerbations and greater lung-function decline than placebo, the opposite of its effect in cystic fibrosis), and EMBRACE 2012, BAT 2013 and BLESS 2013 for long-term macrolide exacerbation prevention. Two were chosen precisely because the evidence is uncomfortable rather than tidy: COMBINE 2006 now sits on the alcohol page because acamprosate showed no efficacy in it despite being guideline first-line, with the transatlantic discrepancy explained rather than glossed; and X:BOT 2018 sits on the opioid page with the point that buprenorphine's intention-to-treat advantage came largely from patients failing to induct onto naltrexone, so the barrier is the induction rather than the drug. A sticker that hides the inconvenient half of a trial is worse than none. The requirement is now a standing authoring step and a pre-deploy check, including where a sticker is not appropriate, since a page on staging or pure workup may legitimately carry none.
- CORRECTION: two vaccine age thresholds were out of date across seven places. Checking whether adult immunization deserved its own page surfaced a live correctness problem instead, and the fix mattered more than the page would have. Pneumococcal conjugate is routine from age 50, not 65 -ACIP lowered it in October 2024, and it is a single dose of PCV15, PCV20 or PCV21, still indicated from 19 with risk conditions, with PCV15 alone requiring a follow-on PPSV23 at least a year later (8 weeks if immunocompromised, or with a cochlear implant or CSF leak) because PCV15 leaves serotype gaps the polysaccharide vaccine covers. The Preventive Care page was contradicting itself, saying "pneumococcal from 50" in one place and "PCV20 ≥ 65" in two others. RSV was two revisions behind in five places, still reading "≥ 60" when the recommendation moved to all adults ≥ 75 plus 50 to 74 with risk conditions (60+ in 2023, then 75+ with high-risk 60 to 74 in June 2024, then high-risk lowered to 50 in April 2025). Both were corrected everywhere they appeared, including the diabetes, COPD and CKD pages where the patient population is exactly the high-risk group. Notably the Preventive Care one-pager was already right, so this was drift in the site text alone. The vaccine section now also says plainly to check the current ACIP schedule rather than memorize it, since it is revised annually and pneumococcal and RSV in particular have changed repeatedly. No standalone immunization topic was built, deliberately -a page presenting itself as "the adult immunization schedule" implies a currency this site cannot maintain, and the stale numbers just found are the evidence for that.
- NEW TOPIC: Pressure Injuries, with printable one-pager #212. A ward problem the site referenced but never explained, and one where two of the correct actions run against instinct. Stages never run backwards: a granulating Stage 4 is documented as a "healing Stage 4" permanently, never downstaged to a 3 then a 2, because full-thickness loss fills with granulation tissue and scar and does not regenerate the fat, muscle and bone that were destroyed -reverse staging claims a recovery that did not happen. And stable dry eschar on a heel is a biological cover, not something to debride: if it is dry, adherent and intact with no erythema, fluctuance, drainage or odor, it is protecting tissue too poorly perfused to close, and removing it opens an ulcer that cannot heal. The page also carries the 2016 NPIAP terminology change ("pressure injury" rather than "ulcer", because Stage 1 and deep tissue injury both occur under intact skin), the staging distinctions that actually get missed (blanchable redness is normal hyperemia and not a Stage 1; slough or eschar excludes Stage 2; unstageable means the base is obscured, and debriding reveals a 3 or 4 that was always there), and the fact that in darkly pigmented skin the color change may not be visible at all, so temperature, firmness and tenderness are what to compare. Plus the pressure-versus-moisture distinction that is the commonest misclassification, why the Braden score runs in the opposite direction to most scores and should be read by subscale, why donut cushions and massage over bony prominences are actively harmful, how to actually offload a heel (under the calf, knee slightly flexed, never under the heel itself), and when a non-healing wound over bone means osteomyelitis -where MRI is the imaging test, bone biopsy is the standard, and a surface swab reflects colonization and will treat the wrong organism. Filed under General Wards, which moves from 33 to 34 topics.
- NEW TOPIC: Male Hypogonadism, with printable one-pager #211. A topic where almost every error happens before treatment is even considered, so the page is built around the diagnostic sequence rather than the prescription. A single convenience-timed testosterone is not a diagnosis: the level must be drawn fasting in the morning (there is a diurnal peak, and an afternoon draw can be substantially lower in the same man), repeated on a separate day because a meaningful proportion of initially low levels are normal on repeat, and never taken during acute illness. Then comes the SHBG trap, which is the commonest reason a man is mislabeled hypogonadal: obesity, insulin resistance and diabetes lower SHBG and drag the total down while free testosterone stays normal, whereas aging, hyperthyroidism and liver disease raise it so an older man can look reassuring while his free testosterone is genuinely low. Only then LH and FSH, where a normal LH against a low testosterone is the abnormality rather than reassurance and should prompt prolactin, iron studies and often pituitary imaging, because the answer can be a prolactinoma. Two treatment errors get their own warnings: never prescribing testosterone to a man who wants children, since it suppresses spermatogenesis frequently to azoospermia with slow and uncertain recovery (use hCG or a SERM instead), and the hematocrit rule (baseline, 3 to 6 months, then annually; stop above 54%, evaluate for hypoxia and sleep apnea, restart reduced; baseline above 50% is a relative contraindication). Also adds TRAVERSE (2023) to the trial database, stating both halves honestly: noninferior to placebo for the primary MACE endpoint, but with more atrial fibrillation, acute kidney injury and pulmonary embolism as secondary signals. Filed under Endocrinology, which moves from 20 to 21 topics.
- NEW TOPIC: Alcohol Use Disorder, with printable one-pager #210. The companion to the opioid page above, and the same shape of gap: the site covered the CIWA protocol and acute withdrawal in depth but had nothing on the chronic disease or its long-term treatment, so acamprosate appeared once site-wide and naltrexone's mentions were all for cholestatic pruritus and obesity. The defining problem here is undertreatment rather than a shortage of options: effective first-line medications exist and only a small minority of patients ever receive one. Two beliefs cause much of that, and the page takes both apart. Naltrexone is not contraindicated in liver disease -the FDA hepatotoxicity boxed warning was removed in 2013 because the evidence did not support it, subsequent studies including patients with cirrhosis have not shown meaningful drug-induced injury, and disulfiram is the agent actually contraindicated there, so the belief withholds treatment from precisely the patients whose survival depends on stopping. And abstinence is not a precondition for prescribing: demanding it up front loses patients who would have accepted help, reduced drinking is a legitimate outcome, and naltrexone's best evidence is specifically for reducing heavy drinking rather than producing total abstinence. Also carries all five agents compared by mechanism and role with verified dosing for the two first-line drugs, a choose-by-comorbidity table (renal impairment favors naltrexone, decompensated liver disease favors acamprosate, concurrent opioid use rules naltrexone out entirely because it precipitates withdrawal and blocks analgesia), how to quantify a standard drink when patients under-report, why an AST:ALT above 2 with low platelets points at advanced fibrosis, and thiamine before glucose. Filed under Ambulatory, which moves from 35 to 36 topics.
- NEW TOPIC: Opioid Use Disorder, with printable one-pager #209. The site covered alcohol withdrawal but had no page on addiction treatment at all, which made it the largest remaining blind spot: buprenorphine appeared four times site-wide and every one was about pain, not opioid use disorder. Two things have changed what a resident can actually do, and both are worth stating plainly because a mental model formed even a few years ago is now out of date. The X-waiver is gone, eliminated by the Consolidated Appropriations Act of 2023, so any clinician whose DEA registration includes Schedule III authority may prescribe buprenorphine with no patient cap. And fentanyl has broken traditional induction: because it is highly lipophilic and redistributes slowly out of fat, patients can precipitate withdrawal even after 8 to 24 hours of abstinence with a convincing COWS score, so "wait for withdrawal, then give a standard dose" no longer guarantees safety. The page covers the two strategies that answer this, low-dose overlap initiation (small escalating doses while the full agonist continues, so the patient does not need to be in withdrawal to start) and high-dose initiation (about 1 to 5 percent precipitated withdrawal in fentanyl-positive emergency department patients). It also carries the two errors that do real harm: never stopping maintenance buprenorphine or methadone to treat acute pain, because the maintenance dose gives no meaningful analgesia and stopping it simply adds withdrawal to the pain, and the fact that a withdrawal-only admission leaves the patient at higher overdose risk than before they arrived, since tolerance falls faster than the drive to use returns. Plus the mortality case for treatment, the three medications compared by mechanism, the methadone dose-verification rule and 72-hour bridge, the infectious screening this population routinely misses, and why the language in the chart is itself part of the treatment. Filed under Ambulatory, which moves from 34 to 35 topics.
- NEW TOPIC: Bronchiectasis, with printable one-pager #208. Built on the 2025 ERS guideline, which replaces the 2017 edition and now recommends airway clearance training universally rather than selectively. Three ideas organize the page. The vicious cycle dictates the treatment: impaired clearance leads to colonization, which drives inflammation, which destroys the airway wall and worsens clearance, so management needs three arms rather than one, and this is a chronic disease with acute flares rather than a run of unrelated pneumonias. Hunting for the underlying cause is the highest-yield thing available at the first visit, because a cause is found in about half of patients and changes management in a real minority: immunoglobulin replacement for antibody deficiency, corticosteroids for ABPA, modulator therapy for cystic fibrosis diagnosed in adulthood. Stopping at "idiopathic" without testing is how a treatable patient never gets treated. And one drug that helps in cystic fibrosis is harmful here: a randomized trial of dornase alfa in non-CF bronchiectasis found more exacerbations and greater lung function decline, because the mechanisms differ and the CF evidence does not transfer. The page also carries why exacerbation courses run about 14 days rather than the 5 to 7 used for pneumonia, why nontuberculous mycobacteria must be excluded before starting long-term azithromycin (monotherapy in unrecognized NTM breeds resistance and wrecks the regimen you would later need), why an ABI-style trap applies to the chest X-ray (radiography is insensitive, so a normal film excludes nothing), and why inhaled corticosteroids are not routine therapy here. Filed under Pulmonology, which moves from 14 to 15 topics.
- NEW TOPIC: Peripheral Artery Disease, with printable one-pager #207. Built on the framing that reorders the whole encounter: PAD is a coronary risk equivalent that happens to present in the legs, and most patients die of myocardial infarction and stroke rather than losing a limb -so the statin, antiplatelet, blood pressure control and smoking cessation matter more than the angiogram, and that is the part of the visit most often skipped. Two things are genuinely counterintuitive and get their own sections. Supervised exercise therapy produces walking improvements comparable or superior to revascularization for claudication, durably and without procedural risk, with a specific prescription (walk to moderate pain, rest, repeat, 30 to 45 minutes, three times weekly, 12 weeks minimum) that has to be explained rather than issued as generic advice. And an ABI above 1.40 is not a good result -it means noncompressible calcified vessels in diabetes or CKD, rendering the test uninterpretable and potentially masking severe disease, so the toe-brachial index is used instead. Also covers recognizing chronic limb-threatening ischemia (rest pain relieved by hanging the leg out of bed), distinguishing vascular from neurogenic claudication, telling arterial from venous and neuropathic ulcers, and correcting the persistent myth that beta-blockers are contraindicated in PAD. Site is now 249 topics and 207 infographics.
- NEW TOPIC: Multiple Sclerosis, with printable one-pager #206. The only major neurologic disease with zero mentions anywhere on the site, written deliberately for the internist rather than the neurologist: you will not start the disease-modifying therapy, but you will see the first attack, the patient who looks like they are relapsing when they are actually infected, and the immunosuppression complications years later. The pseudorelapse gets the strongest warning, because it is the commonest MS error on a general medical ward: infection, fever and heat transiently unmask old deficits through impaired conduction in already-demyelinated axons, with no new inflammatory activity, so the treatment is the infection and steroids treat nothing while adding harm. The page also carries the distinction that causes real damage if missed -a cord lesion spanning three or more segments, or severe or bilateral optic neuritis, means sending AQP4 and MOG antibodies before any DMT, because several MS therapies including interferon beta make NMOSD substantially worse. Rounded out with dissemination in space and time (including how a single scan showing enhancing beside non-enhancing lesions proves both), the DMT complications an internist actually meets (PML on natalizumab, hepatitis B reactivation on anti-CD20 agents, rebound activity on stopping S1P modulators), and the invisible symptoms that carry most of the quality-of-life burden.
- NEW TOPIC: Nephrolithiasis, with printable one-pager #205. Most stones pass and most patients go home, which is exactly what makes the exceptions the point of the page. Obstruction plus infection is a urologic emergency: fever with an obstructed kidney means pus under pressure, which antibiotics cannot penetrate and which progresses to sepsis and irreversible renal damage within hours, so it needs decompression by stent or nephrostomy with definitive stone treatment deferred. A solitary or transplanted kidney makes obstruction functional anuria. The page also flags the mimic that kills -a leaking abdominal aortic aneurysm presenting as first-time renal colic in an older patient- and corrects two overestimated interventions: IV fluids do not flush stones out, and tamsulosin's benefit is modest and concentrated in distal stones over about 5 mm. NSAIDs are first-line and outperform opioids because they reduce ureteral tone and edema as well as pain. Prevention gets equal weight, since recurrence approaches half within a decade: fluid to produce 2 to 2.5 L of urine daily, sodium and animal protein reduction, and the correction of the most counterproductive advice in this disease -never restrict dietary calcium, because it binds oxalate in the gut and restricting it raises urinary oxalate and increases stone risk.
- NEW TOPIC: Thyroid Nodule, with printable one-pager #204. The site covered thyroid emergencies, hypothyroidism and hyperthyroidism but not the commonest thyroid referral. Three ideas organize it. TSH comes first because it is a branch point, not a formality: a suppressed TSH sends the patient to a radionuclide scan, and a hyperfunctioning "hot" nodule is almost never malignant and should not be biopsied -it is treated as hyperthyroidism, so sending one for FNA is a classic wasted step. Sonographic pattern combined with size decides the needle, with the threshold rising as risk falls: suspicious features (solid hypoechoic, microcalcifications, irregular margins, taller-than-wide) are sampled around 1 cm while spongiform and purely cystic nodules are observed -though abnormal cervical nodes, extrathyroidal extension and childhood radiation override size entirely. And overdiagnosis is treated as a real harm rather than a footnote: widespread scanning raised detected thyroid cancer without a matching mortality change, which is why sub-centimeter nodules are usually followed and why active surveillance is legitimate for selected papillary microcarcinomas. Also covers the Bethesda categories (including that nondiagnostic is not benign), why cytology cannot separate follicular adenoma from carcinoma, and the two not-to-miss diagnoses: anaplastic carcinoma as an airway emergency, and medullary carcinoma requiring pheochromocytoma exclusion and RET testing before surgery.
- NEW TOPIC: Celiac Disease, with printable one-pager #203. This is the one diagnosis where the order of events decides whether it can be made at all, so the page leads with it: test before the gluten-free diet starts, because the diet normalizes serology and heals the mucosa within weeks to months, leaving a patient who has already stopped gluten neither confirmable nor excludable -stuck with either a lifelong restrictive diet on no evidence or a missed diagnosis. If they have already stopped, the only routes are a formal gluten challenge or HLA-DQ2/DQ8 typing, which is useful only to exclude (negative rules it out; positive is common in the general population and proves nothing). Two other traps get equal weight: always order total IgA alongside tTG-IgA, since selective IgA deficiency is far more common in celiac disease and produces a falsely negative result in exactly the population being tested, and take at least four distal duodenal biopsies plus bulb samples, because the disease is patchy and undersampling is a recognized cause of false negatives. The page also corrects the presentation stereotype -most adults do not present with diarrhea, and unexplained iron deficiency anemia unresponsive to oral iron is often the only clue- and explains that non-response is usually continued inadvertent gluten exposure rather than refractory disease.
- NEW TOPIC: Dysphagia & Esophageal Disorders, with printable one-pager #202. Organized around the two questions that sort almost every case: where does it stick (oropharyngeal difficulty initiating the swallow, which is usually neuromuscular and goes to a video swallow study, versus esophageal sticking seconds later, which goes to endoscopy) and solids only or solids and liquids (progressive solids means a narrowing lumen; intermittent solids means a fixed non-narrowing lesion; solids and liquids from the outset means the lumen is open but the pump is broken). The page states plainly that dysphagia is always an alarm symptom warranting endoscopy rather than an empiric PPI trial, because esophageal cancer presents exactly this way. Two safety sequences are emphasized: biopsy the esophagus even when it looks completely normal, since eosinophilic esophagitis is a histologic diagnosis and a leading cause of food impaction in young atopic patients, and get a barium swallow before endoscopy when Zenker diverticulum is suspected, because a blindly advanced scope can perforate the pouch. Also covers pseudoachalasia (GE junction malignancy reproducing achalasia exactly), food impaction management including why meat tenderizer is never used, the odynophagia differential, and why feeding tubes do not prevent aspiration pneumonia.
- NEW TOPIC: Diverticulitis, with printable one-pager #201. Three things residents were taught have been overturned, and the page is organized around them. Antibiotics are now selective rather than automatic: ACP 2022 supports initially managing selected patients with acute uncomplicated left-sided disease without them, since randomized trials (AVOD, 2012 and DIABOLO, 2017, together over 1,200 patients) showed no difference in symptom resolution, recurrence or need for surgery. Read that result precisely: both trials showed non-significantly higher rates of complicated disease and surgery without antibiotics, so they exclude a large difference rather than proving equivalence -which is why the recommendation is selective rather than blanket, and the exclusions carry equal weight (suspected complicated disease, recent antibiotic use, unstable comorbidity, immunosuppression, or any sign of sepsis all still get treated), so the decision should be deliberate in both directions. Nuts, seeds, corn and popcorn do not cause diverticulitis, and since patients carry that restriction for decades, lifting it explicitly is part of the visit. And the "two episodes and operate" rule is gone, replaced by an individualized decision on symptom burden, smouldering disease, fistula or stricture, and immunosuppression. What has not changed: CT the first episode, not to confirm but to exclude the mimics, and colonoscopy at 6-8 weeks after complicated disease or in anyone not current with screening, because colon cancer presents exactly as diverticulitis. Includes the Hinchey classification, abscess drainage thresholds, and admission criteria.
- NEW TOPIC: Dizziness & Vertigo, with printable one-pager #200 (the library's 200th sheet). Built around a teaching correction: asking "what do you mean by dizzy?" performs badly, because symptom-quality descriptions are unreliable and change on re-questioning. The page classifies by timing and triggers instead, which maps directly onto the diagnostic categories and tells you which exam to do. The centerpiece is the HINTS exam, including the two things most often gotten wrong: it is valid only in acute vestibular syndrome with continuous vertigo and nystagmus present at the time of examination (applying it to episodic or resolved dizziness manufactures false reassurance), and a NORMAL head impulse test is the alarming result, because an intact vestibulo-ocular reflex in a patient with continuous vertigo means the lesion is central. Any single central feature is enough. Also covers why a normal head CT excludes nothing (insensitive for posterior fossa ischemia, and even early MRI misses a meaningful minority of posterior circulation strokes), why new hearing loss with vertigo suggests AICA infarction rather than benign labyrinthitis, the Dix-Hallpike and Epley maneuvers step by step, and the two vestibular-suppressant errors: they have no role in BPPV, and beyond 72 hours in neuritis they delay central compensation and worsen recovery.
- NEW TOPIC: Low Back Pain, with printable one-pager #199. One of the most common reasons adults see a doctor had zero mentions on the site. The page is built around the two skills that matter: finding the few percent with a red-flag cause, and then not imaging the 90-95% who have nonspecific pain. Cauda equina leads, because it is the miss that ends mobility: new urinary retention is the most consistent early finding (saddle anesthesia and bilateral symptoms are classic but later), a post-void residual is the fastest bedside test, and suspicion means urgent MRI plus immediate surgical consultation rather than a referral. Red flags for malignancy, spinal infection (where epidural abscess can progress to paralysis over hours), fracture, and the inverted inflammatory pattern of axial spondyloarthritis (better with exercise, worse with rest) each get their action. The imaging section explains why early imaging is actively harmful rather than merely wasteful: degenerative findings are present in most asymptomatic adults, and unframed reports anchor patients to a structural explanation, increasing fear-avoidance and leading to more procedures with worse function. Management names what does not work -acetaminophen is ineffective for acute low back pain, gabapentinoids do not work for back pain or sciatica, and systemic steroids do not help- alongside the yellow flags that predict disability better than any scan. Cross-listed under Ambulatory.
- NEW TOPIC: Osteoarthritis, with printable one-pager #198. The most common joint disease and a leading cause of disability had four passing mentions and no page. Three things drive the content. The diagnosis is clinical -over 45 with activity-related pain, morning stiffness under 30 minutes, bony enlargement and crepitus needs no imaging or labs, and MRI is almost never indicated because it finds age-universal changes that generate anxiety and low-value surgery. Radiographs correlate poorly with symptoms in both directions, which is why management follows function, and why the phrase "bone on bone" should be retired: it convinces patients the joint is destroyed and that movement will damage it, producing exactly the fear-avoidance and deconditioning that worsen outcomes. And exercise is the most effective intervention in the disease, drug or otherwise, ahead of every pharmacologic option, with topical NSAIDs first-line for knee and hand disease because they match oral analgesia at a fraction of the systemic risk in the older, renally impaired patients who actually have OA. The page also states plainly what does not work, since patients arrive committed to it: glucosamine and chondroitin, hyaluronic acid injections, PRP and stem cell injections, and arthroscopy for degenerative meniscal tears. Cross-listed under Rheumatology and Ambulatory.
- NEW TOPIC: MASLD & MASH (formerly NAFLD / NASH), with printable one-pager #197. The commonest liver disease in the world was renamed in 2023 and given its first approved drug in 2024, so most of what residents were taught is outdated terminology attached to an outdated plan. The 2023 multisociety consensus replaced NAFLD with MASLD and NASH with MASH, and the change is practical rather than cosmetic: the diagnosis is now positive (steatosis plus at least one cardiometabolic criterion) instead of an exclusion requiring alcohol to be ruled out first, and the new category MetALD names the very common patient with both metabolic risk and meaningful alcohol intake so that both drivers get treated. The page is built on two facts that change practice: fibrosis stage is the only thing that predicts liver outcomes, so the question is never "is there fat" but "is there F2 or worse", answered with a FIB-4 that costs nothing (under 1.3 low, over 2.67 to hepatology, the indeterminate zone to elastography); and cardiovascular disease is the leading cause of death in MASLD, ahead of liver disease, which makes finding it a cardiometabolic risk finding. Two errors are called out explicitly: normal aminotransferases do not exclude advanced fibrosis, and statins are safe here and treat what will actually kill the patient. Also covers the specific weight-loss thresholds worth quoting to patients (3-5% for steatosis, 7-10% for inflammation, 10%+ for fibrosis regression), exercise benefit independent of weight change, lean MASLD, and resmetirom for F2-F3 fibrosis but not cirrhosis. Cross-listed under Gastroenterology and Ambulatory.
- NEW TOPIC: Peripheral Neuropathy, with printable one-pager #196. Ninety-five passing mentions and no page. The organizing principle is that the pattern is the diagnosis: symmetric stocking-glove disease has a short evidence-based lab list, while stepwise asymmetric deficits are nerve infarcts from vasculitis and run on a timescale of days, and progressive proximal-plus-distal weakness beyond 8 weeks is CIDP, which is treatable and therefore the diagnosis not to miss. The first tier is three tests with the reasoning behind each: A1c and then a glucose tolerance test if normal (impaired glucose tolerance causes painful small-fiber neuropathy before diabetes is diagnosable), B12 with methylmalonic acid (the serum assay is insensitive at the low-normal range, and metformin and PPIs deplete B12 over years), and SPEP with immunofixation, since a paraprotein reroutes the case entirely. Also covers when EMG answers a real question versus confirming the obvious, why a normal EMG never excludes small fiber neuropathy (it tests only large fibers), both directions of the vitamin B6 trap, and neuropathic pain treatment with the goal stated honestly at a 30 to 50% reduction. Cross-listed under Neurology and Ambulatory.
- NEW TOPIC: Depression & Anxiety, with printable one-pager #195. The highest-mention gap on the site: depression appeared 211 times in passing with no page behind it, for the most prevalent treatable conditions in primary care. Built around four decisions: score it (PHQ-9 and GAD-7 bands, treatment threshold at 10, remission under 5, re-scored at every visit because treating without trending is titrating blind), two questions before any prescription (the bipolar screen, since antidepressant monotherapy in unrecognized bipolar disease can precipitate mania and bipolar illness usually debuts as depression; and asking about suicide directly, which does not plant the idea, with firearms asked about by name because means restriction is one of the few interventions proven to prevent deaths), choosing the drug by side-effect profile since efficacy is comparable (duloxetine when pain coexists, bupropion when sexual dysfunction or weight matter, mirtazapine for the elderly patient with insomnia and weight loss, the citalopram QT cap), and running an adequate trial: therapeutic dose for 4 to 6 weeks before judging, continuation 6 to 12 months past remission, taper on the way out, and the difference between discontinuation symptoms and relapse. Anxiety gets the same drugs at half the starting dose, CBT as an equal partner, and an honest accounting of why benzodiazepine immediacy is the trap in panic disorder.
- NEW TOPIC: Dementia & Cognitive Impairment, with printable one-pager #194. The site covered delirium but not its outpatient counterpart, despite 59 passing mentions. Organized around two ideas. First, three things must be excluded before the label is applied: delirium (never diagnose dementia during acute illness, because the test measures the delirium and the label then follows the patient forever), depression, and medications, since the reversible contributor is more often in the medication list than on the scan. Second, what comes FIRST names the subtype and the subtype decides what is safe to prescribe: memory first is Alzheimer, behavior first is frontotemporal, hallucinations and fluctuation first is Lewy body, gait first is normal pressure hydrocephalus or vascular. That distinction is a safety decision rather than an academic one, because antipsychotics can cause life-threatening rigidity in Lewy body disease (whose visual hallucinations invite exactly the wrong drug) and cholinesterase inhibitors do not help frontotemporal dementia and can worsen behavior. Also covers anti-amyloid therapy eligibility honestly (early disease with amyloid confirmed by PET or CSF, screening MRI, APOE genotyping because ε4 carriers have higher ARIA risk, surveillance MRIs as part of the therapy, and slowed decline rather than reversal), behavioral symptoms as communication rather than a prescribing trigger, and the care-plan work that outweighs the prescription: caregiver support, early advance care planning while capacity remains, and the evidence that feeding tubes do not help advanced dementia. Cross-listed under Neurology and Ambulatory.
- NEW TOPIC: GERD, Peptic Ulcer & H. pylori, with printable one-pager #193. The third gap from the coverage audit, and the one carrying a genuine practice change: the 2024 ACG guideline retired clarithromycin triple therapy and concomitant therapy as empiric first-line H. pylori treatment, because US clarithromycin resistance crossed the threshold where empiric use is defensible. Bismuth quadruple therapy for 14 days is now the preferred empiric regimen, with vonoprazan dual or triple and rifabutin triple as alternatives, and clarithromycin or levofloxacin reserved for documented susceptibility. Residents taught "PPI + clarithromycin + amoxicillin" as the default are carrying a retired recommendation, so the change is called out explicitly on both the page and the sheet. The topic also covers the alarm features that mean endoscopy rather than an empiric trial, the test-and-treat pathway under 60, the two-week PPI hold before H. pylori testing (the commonest cause of a false negative), mandatory test-of-cure, why gastric ulcers are biopsied and re-scoped while duodenal ulcers are not, and PPI deprescribing with the rebound hypersecretion that gets misread as relapse. Cross-listed under Gastroenterology and Ambulatory.
- NEW TOPIC: Viral Hepatitis (A through E), with printable one-pager #192. The second gap from the coverage audit: 77 passing mentions across the site and no page, for two diseases that are now screen-everyone conditions. Built around the HBV serology panel as a six-answer logic puzzle, including the two patterns that fool people (the window period, where IgM anti-HBc is the only positive marker, and isolated anti-HBc, which still reactivates under immunosuppression). Covers universal screening (HCV for all adults and every pregnancy per CDC 2020; HBV triple panel for all adults per CDC 2023), AASLD treatment thresholds for HBV with the reasoning behind them, the pan-genotypic DAA pathway that cures HCV in 8 to 12 weeks without genotyping, needle-stick management for both viruses, and the extrahepatic syndromes that should trigger testing. Two reactivation checks are given the strongest warning treatment on the page, because both are fulminant-capable and fully preventable: HBsAg plus anti-HBc before rituximab or transplant, and the same panel before any HCV DAA (an FDA boxed warning, since curing HCV lifts its suppression of HBV). Cross-listed under Gastroenterology and Infectious Disease.
- NEW TOPIC: Osteoporosis, with printable one-pager #191. A coverage audit against the core internal medicine curriculum found it the biggest gap on the site: 44 passing mentions and no page, for one of the highest-volume problems in clinic and on the wards. The topic covers the three routes to diagnosis (including that a hip or vertebral fragility fracture IS the diagnosis at any T-score), the January 2025 USPSTF screening criteria, FRAX thresholds and where FRAX under-reads, the secondary-cause workup, risk-tiered treatment with the anabolic-first sequencing logic for very-high-risk patients, bisphosphonate administration rules and drug holidays, the denosumab discontinuation trap (rebound vertebral fractures; a lapsed refill is a patient-safety event), and the hip-fracture admission as the intervention point, where zoledronic acid within 90 days of repair cut refractures ~35% and mortality 28% in HORIZON-RFT yet fewer than a quarter of patients ever start therapy. Cross-listed under Endocrinology and Ambulatory.
- NEW TOPIC: Parkinson Disease, with a dedicated Orthostatic Hypotension tab. Full seven-tab topic under Neurology covering diagnosis (including why DaTscan cannot distinguish PD from the atypical syndromes), levodopa-first therapy, and the two hospital traps that hurt patients: late or held doses (parkinsonism-hyperpyrexia syndrome) and dopamine-blocking antiemetics or antipsychotics on the order set, with the safe substitutes named. The orthostatic hypotension tab carries the bedside clue that separates neurogenic from volume depletion (the heart rate barely rises; a rise-to-drop ratio under 0.5 bpm/mmHg means the baroreflex itself is broken), the treatment ladder from deprescribing through salt, water boluses, abdominal binder and head-up sleeping to midodrine and droxidopa, and the supine hypertension trade-off. Printable one-pager #190 built and QR-verified.
- Major Guidelines updated on every rotation page. All 15 rotation guideline folders were reviewed against current editions, with each change verified against the primary publication. Retired editions replaced: Surviving Sepsis 2021 to 2026, Hypertension 2017 to 2025, Cholesterol 2018 to the 2026 Dyslipidemia guideline, HCM 2020 to 2024, the ACS entry to the unified 2025 guideline, AHA 2020 ACLS/BLS to the 2025 CPR and ECC guidelines, CAP 2019 to ATS 2025, IDSA 2010 UTI to the 2025 Complicated UTI guideline, the 2009-era DKA reference to the ADA/EASD 2024 Hyperglycemic Crises consensus, AABB 2016 transfusion to 2023, WAO 2020 anaphylaxis to the AAAAI/ACAAI 2023 practice parameter, and AAN 2012 GBS to the EAN/PNS 2023 guideline. Mislabels corrected, including KDIGO AKI (the published guideline is 2012; the 2026 AKI/AKD update is still in public review) and a status epilepticus entry whose link did not resolve, now pointing to the governing NCS 2012 guideline. Added where a folder had a gap: ESICM 2023 ARDS to ICU, the 2026 Acute PE guideline to ICU, Pulmonology and EM, and the 2026 CKM guideline to Cardiology and Ambulatory.
- What's New is now a dated timeline. Entries hang on a vertical rail with a colored date dot, and the 2025 updates carry real publication dates (ACS February 27, Hypertension August 14, CAP July, Complicated UTI December) instead of a bare year. The KDIGO CKD entry was mislabeled 2025 and is now correctly dated March 2024, and the section was reordered newest-first to match.
- Visual refresh across the site. Compact homepage hero, rotation cards as tinted inline rows with each rotation carrying its own accent color through its page hero, topic grid (now 3 columns with color dots) and guidelines folder. Quick Reference joined the 4-column grid. The Landmark Trials library was rebuilt: the verdict badge sits above the trial name, each card carries a left border colored by verdict (green positive, red negative, amber neutral, teal guideline), and the PubMed button matches the site accent. Library pages (Pearls, Trials, What's New, About) got the soft hero panel. Topic paragraphs were normalized to the site's type scale.
- Sticky topic navigation now tracks scrolling. The pinned tab bar highlights the section currently on screen as you scroll instead of keeping the last clicked tab lit, and the Antibiotic Guide, the one tabbed page the sticky bar had silently skipped, is now covered.
- Share menu: copy link and native sharing, on every page including the homepage. The share button adds a Copy Link option with clipboard feedback and, on phones, the native share sheet, alongside WhatsApp, email and SMS. It now appears on the front page too, sharing the site itself.
v5.7 - August 12, 2026
- Internal files were publicly readable, and the rule meant to block them had never worked. A post-deploy check found
/CLAUDE.md returning 200 with its full contents, and every infographic HTML source under /infographics/_src/ being served the same way, even though a forced 404 redirect for that exact path had been sitting in the Netlify config. The reason is an ordering rule that is easy to get wrong: edge functions run before the redirect engine. The Open Graph edge function matches every path, and the call it makes to fetch the page reads the static file directly, so the redirect was never reached on any URL. Blocking is now done inside that edge function, ahead of its static-asset shortcut so that source images cannot slip through on their file extension, and the config rules were kept as a fallback in case the edge function is ever removed. The PDFs, thumbnails and everything else under /infographics/ stay public, since those are the product. The .git and .claude folders were checked and are not served at all.
- Every clinical pearl now has a permanent number. All 729 pearls carry a fixed number from #1 to #729, shown on the library card and on Pearl of the Day, so one can be found again or quoted to a colleague instead of being re-hunted by wording. The cards did already show a number, but it was not a real identifier: it counted position within whatever was currently on screen, so the same pearl was #1 under Cardiology and a different number after a search, and two pearls could both show #1 at once. The number now comes from the master list and never moves, whichever rotation filter or search is active. Searching a number jumps straight to it: type 412 or #412 in the pearls search box. That search deliberately still runs as ordinary text as well, because 71 pearls contain "50" and treating the query as a number alone would have quietly hidden every 50 mg dosing pearl from someone who just wanted dosing. So a number search adds a result, it never removes one.
- "Submassive" and "massive" PE retired across the site, and a trial claim corrected. The 2026 AHA/ACC guideline replaced the old massive / submassive / low-risk vocabulary with Clinical Categories A to E, and while the PE one-pager and the top of the PE page had already been rebuilt around the new scheme, the body text of 15 views had not, so a reader could meet both vocabularies in the same session. Every clinical statement now uses the new categories: Category E where the patient has cardiopulmonary failure, C3 to D for RV strain with elevated biomarkers, and C2 where only one of the two is abnormal. Outside the PE topic, where there is no category legend on the page, the old word is kept in brackets so the sentence still reads. Three kinds of mention were deliberately left alone: the old-to-new mapping table, headings that read "formerly massive", and the trial tooltips, since PEITHO, ULTIMA, SEATTLE II, FLARE and FLAME each enrolled by the old definitions and rewriting their criteria would misreport what was actually studied. Searching "submassive" still finds the page, because the mapping keeps the word. Separately, a clinical pearl was wrong and has been rewritten: it credited MOPETT with "less bleeding than full-dose" lysis, but MOPETT had no full-dose arm. It compared half-dose alteplase against anticoagulation alone in 121 patients and no bleeding occurred in either group, so that comparison was never made. The pearl now gives the real comparator and the real result (pulmonary hypertension 16% vs 57% at 2.3 years, no mortality benefit, single center).
- Site-wide topic count corrected, and one place that still had the old number. The description shown to search engines and social previews claimed 263 evidence-based protocols in seven places while the site actually has 249, and the search keywords line still read "240+ protocols", a number a previous cycle recorded as having been corrected everywhere. All eight now read 249, matching the sitemap exactly. Historical changelog entries were deliberately left alone, since those describe what was true at the time and rewriting them would erase the record. Every other published figure was recounted from the page source and confirmed unchanged: 231 topics and tools, 15 rotations, 1,070 pimp questions, 1,803 trial citations, 1,165 alert flags, 569 clinical scenarios, 729 pearls and 189 infographics. The one that had drifted was drug-table entries, corrected from 6,192 to 6,179 across 1,103 tables, the small reduction left by removing the Quick Reference tabs.
- The app now opens instantly on repeat visits, and pages reached from Google stop reloading on every click. Two things were slowing the site down. The offline system was set to always wait for a fresh download before showing anything, so the stored copy was never used for speed, only for being offline: every visit, even by someone who had been reading an hour earlier, sat waiting on the network first. Worse, the change that gave each topic its own indexable page means a page opened from a search result contains only that one topic, so clicking through to any other topic forced a complete page reload, measured at up to 3.7 seconds each time. Someone arriving from Google was effectively getting a brand new page load for every topic they opened. The site now keeps a complete copy of itself and serves that, so it appears immediately and every topic is already there to switch to, which measured at about a third of a second instead of a reload. It also means the whole reference now works with no connection at all, which matters on hospital wifi. Search engines are unaffected and still receive the one-topic-per-address version, so indexing is unchanged. Because the stored copy can be one version behind, a "an updated version is available" prompt with a Refresh button now appears whenever a new build is detected, including when you return to the tab, so a clinical correction reaches readers in seconds rather than sitting unseen.
- "Print Infographic" now opens the sheet immediately instead of stalling for 2.5 seconds. The button used to load the one-pager into a hidden frame and try to print it, waiting 2.5 seconds before giving up and opening it in a new tab. Testing on the live site showed that attempt can never succeed in Chrome: it renders PDFs in an internal viewer that counts as a separate origin, so a page is not permitted to press print on a PDF it has embedded, no matter how the security settings are arranged. The result was that every click did nothing at all for two and a half seconds and then opened the tab anyway. The button now opens the sheet straight away, where the print button and Ctrl+P work normally. Being honest about it: this is one keystroke rather than a print dialog appearing by itself, which is not achievable for an embedded PDF in current browsers, and the printed result is the full-quality vector sheet rather than a downscaled image.
- Infographic thumbnails moved to WebP, cutting 35 MB. All 378 preview images (a 520 px copy for the library cards and a 1040 px copy for retina screens) were JPEG at near-maximum quality, which is the worst case for dense text: re-encoding them as JPEG at a lower setting saved only about 15% and started to blur small type. WebP at the same visual quality took the set from 89.0 MB to 53.9 MB, a 39% reduction, verified by comparing text-dense crops at full magnification before and after so that subscripts like HCO₃ stay legible. Total site content is now 97.1 MB. The pixel dimensions were deliberately left alone: they match exactly what the embed and the library grid render at, so shrinking them would show as soft thumbnails on modern phones. The build script now produces WebP for any new sheet automatically.
- Dashboard banners removed, Pearl of the Day promoted. The Surviving Sepsis 2026 and 2026 ACC/AHA Dyslipidemia banners had been sitting on the homepage since March, and both had outlived their news value while two newer guidelines (acute PE in March, CKM in June) never got a banner at all. Together they consumed 158 px above the fold, which was enough to push the rotation grid, the actual navigation, off the first screen. With both removed, Pearl of the Day rises from 436 px to 274 px and the first rotation card moves from 795 px to 584 px, so the grid now sits above the fold at a standard viewport height. The hero already links to current guidelines, so nothing was lost in the way of surfacing new content.
- Six stale rotation topic counts corrected. The homepage rotation tiles were each under-reporting by one: ICU 26 to 27, Cardiology 25 to 26, Nephrology 14 to 15, Emergency Medicine 16 to 17, Endocrinology 17 to 18, Ambulatory 25 to 26. Four were the CKM page, which was added to those grids without its count being carried through; the ICU and Emergency Medicine tiles had drifted earlier. Every tile was then re-checked against the live number of cards in its grid, and all 14 now agree.
- CKM: the COR tags now explain themselves. The page marked recommendations COR 1 and COR 2a but never said what COR meant, and those six tags were the only use of that notation on the entire site, which otherwise writes "Class I" in 91 places. A short legend now sits immediately above the first tagged table: COR is the Class of Recommendation, COR 1 means benefit far outweighs risk and is worded "is recommended", COR 2a means reasonable and worded "can be useful", COR 2b is "may be considered", and COR 3 means do not do it. It also says why the distinction earns its place on this page: annual lipids, glycemia, blood pressure and eGFR with UACR are COR 1, while pre-HF biomarker screening is only COR 2a, so the first set is expected and the second is a defensible judgment call.
- Lipid infographic switched from COR to Class notation. The printed sheet used "COR 1" in three places, the only infographic in the library of 154 to use that abbreviation. A one-pager is read standalone, pinned to a wall or reached by its QR code, so it has no page around it and no room for a legend to explain an acronym. It now reads "Class 1", which is the plain-English form and matches the 91 places the rest of the site already writes "Class I". The CKM topic page deliberately keeps COR, because it now defines the term on the page and the extra precision of COR 2a versus COR 1 is doing real work there. Re-rendered at 788.8 pt, still single-page and inside the fill window, thumbnail rebuilt and QR re-verified.
- NEW INFOGRAPHIC #155: CKM Syndrome, and a coverage audit that sized the real gap. An audit of all 204 clinical topic pages against the library found 146 with a printable sheet and 58 without. Fourteen of those 58 are quick-reference views that are already pocket cards in their own right (ECG interpretation, IV fluids, code blue, lab interpretation and similar) plus the library page itself, which leaves 44 genuine clinical topics with no one-pager. The audit also checked for near-duplicates before anything was written, which removed candidates that only looked like gaps: an "ACS Overview" sheet would have substantially duplicated the existing STEMI (#57) and NSTEMI (#58) sheets. Confirmed as real gaps with no overlap: obesity and GLP-1 agents (no sheet at all), outpatient diabetes (only the inpatient sheet #87 exists) and chronic thyroid disease (only the emergencies sheet #84). The first sheet of that campaign is now built: CKM Syndrome, covering the five stages with the Stage 3 criteria spelled out, screening set by stage, the four CKD drug thresholds that are easiest to confuse (RAS inhibitor at UACR 30 with eGFR 30, SGLT2i at UACR 200 with eGFR 20, the Class 2a SGLT2i band at UACR 30 to 199 without diabetes, and finerenone at UACR 30 with eGFR 25 despite the other two rather than instead of them), the type 2 diabetes routing where the trigger is cardiovascular risk rather than A1c, and the two reversals worth knowing. Rendered at 786.5 pt on the first pass, single page, QR machine-verified. Library is now 155 sheets.
- NEW INFOGRAPHIC #156: Obesity Management and GLP-1 Agents, the first topic in the gap list with no sheet of any kind. Covers the three eligibility tiers (lifestyle for everyone at 5% to 10%, pharmacotherapy at BMI 30 or 27 with a comorbidity, surgery above that), full titration schedules for tirzepatide (2.5 mg weekly stepping by 2.5 to 15) and semaglutide (0.25 stepping to 2.4) with the weight loss each achieved in SURMOUNT-1 and STEP 1, and the SELECT result that makes these cardiometabolic rather than cosmetic drugs: 20% MACE reduction in 17,604 adults with established CVD and obesity but no diabetes, largely independent of how much weight was lost. Two reversals are called out because both are still widely taught the old way. The 2023 ASA advice to hold weekly GLP-1s for a week before surgery was replaced by the December 2024 multi-society guideline under which most patients continue, with individualized assessment instead of an automatic stop. And the bariatric surgery threshold moved in 2022 to BMI above 35 regardless of comorbidity, with 30 to 34.9 considered if metabolic disease is present, so quoting the NIH 1991 numbers under-refers patients who now qualify. The sheet also carries what gets skipped before a prescription is written: excluding secondary causes, swapping the obesogenic drug first (antipsychotics, insulin, glucocorticoids, mirtazapine, gabapentinoids, beta-blockers), screening the travelling comorbidities, the 12-week non-response checkpoint at under 5%, and the double-dosing trap where Wegovy and Ozempic are the same molecule under different brands and maximum doses. First render came in underfilled at 637.3 pt, which is what surfaced those omissions; final render 782.8 pt, single page, QR verified. Library is now 156 sheets.
- NEW INFOGRAPHIC #157: Outpatient Type 2 Diabetes, built on the ADA Standards of Care 2026. Carries the individualized targets (A1c under 7% for most, under 8% where life expectancy is limited or hypoglycemia is a risk, because a tighter number in a frail patient causes harm rather than earning credit), blood pressure under 130/80 with systolic under 120 encouraged at high cardiovascular or kidney risk, the diagnostic thresholds and the prediabetes band, and the situations where the A1c cannot be trusted at all (hemoglobinopathy, recent transfusion or blood loss, hemolysis, iron deficiency, erythropoietin, advanced CKD, dialysis, pregnancy). The core of the sheet is that drug choice follows the comorbidity, not the A1c: GLP-1 RA or SGLT2i are started for the organ indication independent of the A1c and independent of whether the patient is on metformin, and ADA 2026 moves them earlier, considered from the point of diagnosis in high-risk patients. It also reconciles two 2026 guidelines that sound contradictory, since ADA keeps metformin first-line for glycemia while the CKM guideline calls it a Class 2a add-on after the cardioprotective agent. Both say the same thing from different starting points: the organ-protective drug is chosen for the organ and metformin is chosen for the glucose. Rounded out with the annual screening set (the UACR is the one most often skipped), insulin initiation at 10 units or 0.1 to 0.2 units/kg titrated against the fasting glucose, a CGM time-in-range target above 70% with under 4% below 70 mg/dL, and the safety items: euglycemic DKA, the expected early eGFR dip on an SGLT2i that should not trigger stopping the drug, metformin as a lactic acidosis question rather than a kidney one, and not stacking a DPP-4 inhibitor on a GLP-1. First render was underfilled at 652.3 pt, which surfaced the missing diagnostic criteria; final 797.8 pt with 16.4 pt of footer clearance. Library is now 157 sheets.
- NEW INFOGRAPHICS #158 to #160: the heme malignancy cluster, which until now had only the pancytopenia sheet between three major topics. #158 Multiple Myeloma carries the IMWG requirement that both halves be present (clonal plasma cells plus a myeloma-defining event), CRAB with its numeric cutoffs, and SLiM with the explanation of why it exists: 60% plasma cells, a free light chain ratio of 100 or more, or two focal MRI lesions identify patients whose progression is near-certain, so they are treated before the kidney fails or the vertebra collapses. It also places the patient on the spectrum (MGUS versus smoldering versus active disease, with the thresholds), flags AL amyloidosis as the mimic that damages organs without meeting myeloma criteria, gives R-ISS with its survival figures, and states three workup points that are commonly wrong: order SPEP, UPEP and serum free light chains together because roughly 20% are light-chain only, the plain skeletal survey is obsolete, and bone scan is the wrong test because myeloma lesions are purely lytic. #159 Acute Leukemia leads with the instruction that matters most: if APL is possible, start ATRA on suspicion without waiting for cytogenetics, because the deaths are from coagulopathy in the first days. Then the four first-48-hour emergencies (febrile neutropenia with the 60-minute clock, tumor lysis including that rasburicase is contraindicated in G6PD deficiency and that asymptomatic hypocalcemia should not be corrected, leukostasis with the caution against transfusing red cells before cytoreduction, and DIC), differentiation syndrome with dexamethasone at first suspicion, and what treatment actually involves so the ward team can anticipate the toxicity. #160 Lymphoma covers excisional biopsy rather than FNA and why, Lugano staging, IPI, Deauville and response-adapted therapy, first-line by disease including the POLARIX result (879 patients, 5-year PFS 64.9% versus 59.1%, HR 0.77, strongest in higher IPI so a risk-directed choice rather than a blanket replacement), the aggressive-is-curable paradox, four named lymphomas with twists that cannot be guessed (Burkitt as an emergency, mantle cell, gastric MALT where eradicating H. pylori alone can cure early disease, and primary CNS lymphoma where steroids before biopsy can make the lesion vanish), and the single most consequential item: screen HBsAg and anti-HBc before rituximab, since reactivation can be fatal and is preventable. All three needed content added after underfilled first renders (569 pt for leukemia, 535.3 for lymphoma), which is again how the omissions were found. Library is now 160 sheets.
- NEW INFOGRAPHICS #161 to #163, plus a duplicate avoided. #161 Amyloidosis leads with the clue that makes the diagnosis, heart failure with thick walls but low ECG voltage, then separates AL from ATTR and AA because the treatments have nothing in common, and states the sequence that must not be reversed: screen for a light chain first, prove amyloid with Congo red, then type it by mass spectrometry. A red warning box carries the error that matters most: a positive PYP scan does not diagnose ATTR on its own, because PYP can be positive in AL too, and calling ATTR on the scan alone in a patient who has AL starts the wrong treatment in the disease where delay is measured in months. Also the inverted cardiac drug rules (preload dependent, so beta-blockers and vasodilators are tolerated badly, and digoxin binds amyloid fibrils), and the point that an MGUS alongside unexplained heart failure, neuropathy or proteinuria is not incidental. #162 Hyperviscosity Syndrome is built around it being a clinical rather than laboratory diagnosis: treat on the triad and the fundus without waiting for a viscosity result. Explains why IgM causes most cases despite Waldenstrom being far rarer than myeloma (a large pentamer that stays intravascular, which is also why plasmapheresis works so well), and carries the two errors that hurt: do not transfuse red cells before pheresis, and beware the rituximab IgM flare. #163 Hypocalcemia and Hypoparathyroidism mirrors the existing hypercalcemia sheet: correct for albumin first, let PTH split the differential, then read the phosphate to split it again. The recurring theme is magnesium, which must be replaced before any hypocalcemia is called refractory, alongside why chronic hypoparathyroidism needs active vitamin D (no PTH means no 1-alpha hydroxylation) and why the calcium target is deliberately low-normal to avoid nephrocalcinosis. It is linked to both the hypocalcemia and hypoparathyroidism topics from one sheet. A fourth gap was closed without writing anything. The uncovered "hypercalcemia of malignancy" topic turned out to be fully served by the existing hypercalcemia sheet #86, which already carries the PTH split, PTHrP, calcitonin, denosumab and the granulomatous causes, so that sheet was linked to the second topic rather than a near-duplicate being authored, the same call made earlier against building an "ACS Overview" sheet on top of the existing STEMI and NSTEMI ones. Library is now 163 sheets.
- NEW INFOGRAPHICS #164 to #167: the rheumatology cluster, which had sheets for lupus, ANCA vasculitis, gout, antiphospholipid syndrome and GCA/PMR but nothing for four common topics. #164 Rheumatoid Arthritis is built on the ACR 2021 guideline: methotrexate as the anchor drug, treat-to-target with a named score, steroids as a bridge only, and the four drug classes with what each one costs you (tocilizumab normalizes the CRP so it can no longer detect infection; JAK inhibitors carry the class boxed warning after a safety trial found more cardiovascular events and malignancies against a TNF inhibitor in patients over 50 with a risk factor). It carries the pre-biologic checklist that prevents disasters, and three pearls that matter on the ward: never combine methotrexate with trimethoprim-sulfamethoxazole (both antifolates, severe pancytopenia), leflunomide needs a cholestyramine washout, and ask about the neck before any intubation, because atlantoaxial subluxation in longstanding disease can compress the cord on extension. #165 Scleroderma Renal Crisis is organized around one instruction: start captopril and do not stop it when the creatinine rises, because stopping converts a recoverable crisis into permanent dialysis. It flags that glucocorticoids are the classic trigger, that around 10% are normotensive, that the microangiopathy mimics TTP but is treated with an ACE inhibitor rather than plasma exchange, and that ARBs are not a substitute. It also carries the counterintuitive prophylaxis paradox: ACE inhibitors treat the crisis but prior ACE inhibitor use has been associated with a higher risk of developing it, so they should not be prescribed preventively. #166 Dermatomyositis and Polymyositis is built around the antibody deciding the plan: anti-synthetase and anti-MDA5 for lung disease (MDA5 with rapidly progressive ILD and often a normal CK, so a normal CK must not reassure), anti-TIF1-gamma and anti-NXP2 for malignancy, and anti-HMGCR statin-associated necrotizing myopathy, which does not resolve on stopping the statin and needs immunosuppression. A red box states that adult dermatomyositis is paraneoplastic until proven otherwise and that a negative initial cancer search does not close the question. #167 Seronegative Spondyloarthropathies covers inflammatory back pain (pain that improves with exercise and not with rest being the most discriminating feature), MRI of the sacroiliac joints detecting sacroiliitis years before plain films, and the two treatment points that separate it from rheumatoid arthritis: methotrexate and sulfasalazine do not work for axial disease, and the comorbidity picks the biologic, because IL-17 inhibitors can trigger or worsen inflammatory bowel disease. Library is now 167 sheets.
- CLINICAL CORRECTION: obeticholic acid was removed from the site, because it no longer exists in the US. While verifying content for a new PBC sheet, a check of current second-line therapy found that Ocaliva (obeticholic acid) was withdrawn from the US market at FDA request over a risk of serious liver injury, including in patients without cirrhosis, with the transition period ending in November 2025 and the approval formally withdrawn. The site was still recommending it in 8 places across the PBC and PSC topic: a treatment bullet, a drug-table row with dosing, a management list, a summary tile, a One Pager step, a One Pager drug row, a "do not do" item and a referral criterion. All now name the current second-line agents, elafibranor (Iqirvo) 80 mg daily and seladelpar (Livdelzi) 10 mg daily, both PPAR agonists given with UDCA or alone if UDCA is not tolerated, and each carries an explicit note that obeticholic acid was withdrawn and should not be prescribed. The historical POISE trial citations were left intact, since they accurately describe what that trial showed. This is the exact failure mode the guideline surveillance rule exists to catch: nothing was broken, the audit stayed green, and the page would have kept telling residents to prescribe a drug that had been pulled from the market.
- NEW INFOGRAPHICS #168 to #170. #168 PBC and PSC separates two cholestatic diseases that behave nothing alike: PBC has AMA, small intrahepatic ducts and genuinely effective therapy, while PSC has a beaded MRCP, an inflammatory bowel disease association that warrants colonoscopy even without symptoms, and no medical therapy that alters the disease, with high-dose UDCA actively harmful. It carries the corrected PBC ladder above, the rule that a dominant stricture needs tissue before dilating because cholangiocarcinoma hides there, and a mimics table led by IgG4-related sclerosing cholangitis, which looks like PSC but responds dramatically to steroids, so IgG4 should be checked in every new PSC. #169 Pheochromocytoma and Paraganglioma enforces the order that keeps patients alive: metanephrines drawn supine before imaging, imaging before surgery, and alpha blockade for 7 to 14 days before any beta blocker, since a beta blocker first leaves alpha-mediated vasoconstriction unopposed. It also covers the interfering drugs that cause false positives, that around 40% are hereditary so everyone is referred for genetic testing, the post-operative hypotension and hypoglycemia to expect, and a spell differential led by panic disorder, since most patients tested do not have the tumor. #170 Autoimmune Hepatitis covers the composite diagnosis, why antibody titers should not be followed while IgG should, treating for at least 2 to 3 years because relapse after withdrawal is common, and a dedicated section on acute severe disease, where antibodies may be negative, steroids should be started promptly, and the transplant center is contacted in parallel rather than after steroids fail. Library is now 170 sheets.
- NEW INFOGRAPHICS #171 to #173: the infectious disease cluster. #171 Syphilis is organized around the fact that the stage sets the dose: a single 2.4 million unit dose of benzathine penicillin G for primary, secondary and early latent disease, but three weekly doses for late latent or unknown duration, which is the commonest real-world situation. It flags that neurosyphilis is not a late stage and that ocular or auditory symptoms at any stage are treated as neurosyphilis without waiting for a lumbar puncture, carries the prozone phenomenon in which a very high titer makes the RPR read falsely negative precisely in secondary syphilis and pregnancy, and defines cure numerically as a fourfold fall in RPR at 6 and 12 months. Pregnancy gets its own section, since penicillin is the only regimen that prevents congenital syphilis and allergic patients must be desensitized rather than switched to doxycycline, with maternal treatment needing to be at least 30 days before delivery. Prevention now includes doxy-PEP per the CDC 2024 guidance: 200 mg of doxycycline within 72 hours after sex for men who have sex with men and transgender women with a bacterial STI in the past year, which cut syphilis and chlamydia by over 70%. #172 Herpes Simplex leads with a red box instructing that suspected HSV encephalitis is treated with IV acyclovir immediately, without waiting for PCR, MRI or lumbar puncture, and notes that an early negative CSF PCR does not exclude it. It sets out that PCR is the test while the Tzanck smear is obsolete and IgM unreliable, gives the first-episode, recurrent and suppression regimens separately, explains why episodic treatment must be patient-initiated within the prodrome to work at all, and adds a genital ulcer differential where painful and multiple points to HSV while painless and indurated points to syphilis. #173 Herpes Zoster covers the 72-hour antiviral window, the honest caveat that antivirals do not reliably prevent postherpetic neuralgia, and the two sites needing same-day specialists: ophthalmicus with the Hutchinson sign, and Ramsay Hunt, which is missed whenever a facial palsy is diagnosed without looking in the ear and which recovers worse than Bell palsy. Also zoster sine herpete, sacral zoster causing urinary retention, that exposure risks varicella in the contact rather than zoster, and the two-dose non-live recombinant vaccine for everyone from 50, or from 19 if immunocompromised. Library is now 173 sheets.
- NEW INFOGRAPHICS #174 to #177: the multisystem cluster. #174 Sarcoidosis makes the point that the Scadding stage describes the radiograph and does not tell you to treat: the threshold is significant symptom burden or organ dysfunction, so an asymptomatic Stage II patient is observed while a Stage I patient with cardiac involvement is treated urgently. It flags Lofgren syndrome, where roughly 90% remit spontaneously and steroids are not indicated, the organs that are treated regardless of symptoms (cardiac, neurologic, ocular, severe hypercalcemia), and two errors: serum ACE is not a diagnostic test, and every biopsy needs mycobacterial and fungal culture, because starting steroids in undiagnosed tuberculosis is the trap this diagnosis invites. #175 PRES is built around the name being misleading on both counts, since it is neither always posterior nor always reversible. Covers why the rate of blood pressure rise matters more than the number and that 20% to 30% are normotensive, the ADC and diffusion findings that separate vasogenic edema from an infarct, that calcineurin inhibitors cause it at therapeutic levels so a normal level is no reassurance, and a mimics table led by stroke and RCVS, where getting it wrong cuts both ways since thrombolysis in PRES is harmful. #176 Calciphylaxis leads with the fact that pain out of proportion precedes any visible lesion, then reads as a list of things to stop today: warfarin above all, since it blocks matrix Gla protein and directly drives vascular calcification, plus calcium binders and active vitamin D. Sodium thiosulfate is presented honestly as widely used and biologically plausible but supported by observational rather than randomized evidence, and the sheet states the roughly 50% one-year mortality with sepsis as the usual cause of death, arguing for palliative input alongside active treatment rather than after it. #177 Renal Transplant Medicine opens with two overriding rules for the on-call team: never stop immunosuppression without the transplant center, and check every new drug for a calcineurin interaction. It gives the infection timeline that narrows the differential faster than anything else, and works the rising creatinine in order, including the counterintuitive point that BK nephropathy is treated by REDUCING immunosuppression while rejection is treated by increasing it, and the two can look identical on creatinine alone, which is exactly why the biopsy matters. Library is now 177 sheets.
- NEW INFOGRAPHICS #178 to #181, plus three gaps closed with no new content at all. Before writing anything, the existing palliative sheets were read in full rather than searched, which showed that #116 goals-of-care already covers the family meeting comprehensively (SPIKES, REMAP, NURSE, surrogate and substituted judgment) and #117 hospice already carries the prognostication content (the surprise question, ECOG, FAST, disease-specific criteria). Both were relinked to those topics instead of near-duplicates being authored, and the lipid sheet #154 was relinked to the dyslipidemia guideline page it was built from. A fourth apparent gap, hypoparathyroidism, turned out to be already served by #163. #178 Opioid Rotation and Conversion is built around the step that is skipped: convert to oral morphine equivalents, then reduce by 25% to 50% for incomplete cross-tolerance, since tolerance to one opioid does not transfer fully to another and omitting this is the classic cause of iatrogenic overdose. It states honestly that equianalgesic tables are approximations that disagree with each other and were derived from single-dose studies in opioid-naive people, so the local table should be used and any conversion treated as a starting estimate. Breakthrough is 10% to 20% of the daily total, and methadone is flagged as non-linear and specialist-only. #179 Code Status and Advance Directives separates the documents that are wishes from the ones that are orders, and leads on the misunderstanding that matters most: DNR applies only to cardiac arrest and does not mean do not treat, with the reminder that a DNR is not automatically suspended for surgery and that deactivating an ICD is a separate order. #180 Non-Opioid Symptom Management organizes nausea by receptor rather than by habit, since the commonest reason an antiemetic fails is that it was aimed at the wrong pathway, and covers breathlessness (low-dose opioid first-line, a fan to the face, oxygen only if hypoxic), delirium, secretions and the less common symptoms. #181 Palliative Extubation states the governing principle explicitly, that an intervention no longer meeting the goals is being withdrawn rather than care, and that doses adequate to relieve observed distress are appropriate even if they may hasten death as a foreseen but unintended effect. It carries the absolute rule that no patient is extubated while any neuromuscular blockade remains, that titration follows observed distress rather than blood pressure or saturation, and that under-treatment is far more common than over-treatment. Library is now 181 sheets.
- NEW INFOGRAPHICS #182 to #185, and both cardiology gaps closed without writing anything. Reading #63 valvular-heart-disease end to end showed it already covers aortic stenosis with the full TAVR versus SAVR age and life-expectancy decision, and mitral regurgitation split into primary and secondary with the operative thresholds, so it was relinked to both topics rather than two near-duplicate sheets being authored. That is the fifth and sixth gap closed this way. #182 Preventive Care and Screening is organized around the fact that the retired numbers are the ones still quoted: colorectal now starts at 45, breast is biennial from 40 to 74 after the 2024 update rather than from 50, cervical is HPV primary screening every 5 years from 30 to 65 now including self-collection, and lung screening starts at 50 with a 20 pack-year history rather than 55 and 30. It also explains that USPSTF grades are instructions, since a Grade D such as PSA at 70 and over means do not screen rather than discuss, and adds the adult immunization schedule. Worth recording how this one was verified: the first search returned breast screening as 50 to 74, the pre-2024 recommendation, and only a second targeted search confirmed the current 40 to 74. Screening ages are exactly the content where a stale search result reads as authoritative. #183 Cushing's Syndrome puts exogenous glucocorticoids as step zero, since they are by far the commonest cause and working one up as a tumor is the classic wasted month, then requires two concordant confirmatory tests before ACTH is measured, flags pseudo-Cushing explicitly, and notes that inferior petrosal sinus sampling is needed more often than expected because pituitary microadenomas are frequently invisible while incidental pituitary lesions are common. It also calls out the markedly raised VTE risk, which is the complication most often overlooked perioperatively. #184 Falls Risk and Prevention screens with three questions, and is honest about what works: exercise is the strongest single intervention and the medication review is the highest-yield thing you personally control, while vitamin D is not recommended for fall prevention in community-dwelling adults and bed alarms have not been shown to reduce inpatient falls, with restraints causing harm. It also states that "mechanical fall" is not a diagnosis but a phrase that ends the thinking. #185 Smoking Cessation leads on combining pharmacotherapy with behavioral support, notes the varenicline neuropsychiatric boxed warning was removed so it should not be withheld on that basis, covers combination NRT and the technique errors that make it fail, and includes the interaction most often missed: quitting raises levels of CYP1A2 substrates including clozapine, olanzapine and theophylline, because it is the smoke rather than the nicotine that induces the enzyme. Library is now 185 sheets.
- NEW INFOGRAPHICS #186 and #187, closing four more gaps. #186 Rare and Imported Infections deliberately replaces what would have been three thin sheets. Hantavirus, Ebola and cyclosporiasis are individually too narrow to justify a printed page for a US internal medicine audience, so one sheet covers the part that is actually actionable: the exposure history, isolation, and the phone call. It opens with the rule that malaria must be excluded before anything else in a febrile returned traveler, since it kills within days while the interesting diagnoses are being considered, and a single negative smear does not exclude it. Each of the three then carries the one fact that changes management: only Andes virus transmits person to person, so North American hantavirus cases do not need isolation; Ebola patients are not contagious until symptomatic and the health department call comes before the workup; and routine ova and parasite testing does not detect Cyclospora, which must be specifically requested and may need several specimens, then treated with TMP-SMX. Also the reminder to warn the laboratory before sending specimens that cause laboratory-acquired infection, and to screen for strongyloides before any steroid. #187 Discharge Planning treats discharge as a handoff rather than an event: medication reconciliation drug by drug with the reason for every change, follow-up that exists rather than an instruction to arrange it, a named owner for every pending result, teach-back to confirm the plan landed, and the practical barriers (cost, transport, dexterity, home safety) that are almost never medical and take days to solve, which is why planning starts on day one. It is honest that not all readmissions are preventable, and that for advanced illness the right plan may be a goals-of-care conversation rather than tighter follow-up. Library is now 187 sheets.
- NEW INFOGRAPHICS #188 and #189, the thyroid pair, written to a deliberately limited scope. These two were held back for several cycles because the ATA 2026 guideline on thyroid disease in preconception, pregnancy and postpartum replaced the 2017 guideline, and the full text was not available to verify against. They are now published covering non-pregnant adults only, with an explicit scope note directing pregnancy and postpartum management to the 2026 guideline rather than extrapolating from the sheet. #188 Hypothyroidism leads with two things to settle before prescribing: treat adrenal insufficiency first, since levothyroxine raises cortisol clearance and can precipitate an adrenal crisis, and do not diagnose from tests taken during acute illness. It gives the 1.6 microgram/kg replacement dose with the reasons to start low, the absorption rules that explain most treatment failures, the 6 to 8 week recheck interval and why checking earlier gives a wrong answer, the point that central hypothyroidism cannot be monitored with TSH at all, and an honest treatment of subclinical disease including stopping a trial that does not help rather than escalating it. #189 Hyperthyroidism and Graves' Disease is built around establishing the cause first, because thyroiditis must not be treated with antithyroid drugs: the gland is leaking stored hormone rather than overproducing, so a thionamide does nothing. It covers the three definitive treatment options with the factors that choose between them, the agranulocytosis and hepatotoxicity counseling that matters more than any monitoring schedule, and the commonest monitoring error in the disease, which is that TSH stays suppressed for months and titration must follow free T4 and T3. The same review found a stale citation already published. The hypothyroidism topic page carried trimester-specific TSH targets explicitly attributed to the 2017 ATA guideline, in five places including a worked clinical case. Those numbers could not be corrected without the 2026 full text, so an amber alert now marks the pregnancy guidance on that page as predating the current guideline and directs readers to check it, which removes the false appearance of currency without asserting numbers that have not been verified. Library is now 189 sheets, and every clinical topic page that warrants a printable one-pager has one.
- Deploy check caught a wrong trial year that was live on the site. The pre-deploy RCT_DB step compares the trial database against the last commit, which showed the CONFIRM key had been corrected to
CONFIRM_2021 while the visible trial card still read "2024 · NEJM", as did one inline citation. Verified against the primary publication: CONFIRM was published in NEJM on 4 March 2021 (Wong et al., N=300, HRS-AKI reversal 32% vs 17%). Both display instances corrected to 2021. The same check confirmed the other six RCT_DB key removals this cycle were duplicate cleanups, not data loss: each removed key (ISIS_2_1988, MADIT_II_2002, PARADIGM_HF_2014, PROVE_IT_2004, Girard_ABC_2008, HI_PEITHO_2026_DB) still exists under its dash-form equivalent, and there are zero dangling references to any removed key, so no tooltip is broken.
- The "Quick Reference" tab was removed from all 19 topics that still had one. These were a legacy third summary layer, superseded twice over: every one of those topics already has both a Summary tab and a One Pager tab carrying the real printable infographic. Most of their content was template filler of exactly the kind the audit was built to catch, lines such as "Diagnose: see Overview tab for criteria" and "Treat: evidence-based algorithm, see Management tab", and each card also instructed the reader to press Ctrl+P to print the page, which the new print button has made wrong. 19 section-anchors and 18 tab buttons were removed, about 31,000 characters of markup; the count differs because one section had no button at all and was already unreachable. Before deleting, every affected topic was checked to confirm it kept another summary surface, and all 19 did. Removal used depth-aware boundaries with a div-balance assertion rather than naive slicing, and the result is confirmed by the audit: DOM parity fell by exactly 19, from 1427 to 1408, with no orphan tabs, meaning no tab now points at a section that no longer exists. Deliberately untouched: the
qr-* pocket-card guides whose category label reads "Quick Reference", the "Quick Reference Card" headings inside One Pager sections, and content headings such as "Murmur Quick Reference", none of which are topic tabs.
- Every print button now prints the one-page infographic instead of the protocol page. There were two button classes and both were converted: 225
print-btn in the topic hero and 97 op-print-btn inside the One Pager sections, 322 in total across all 204 clinical topic views. The new printOnePager() reads the current view, looks it up in a generated IG_PDF map, then loads that sheet into a hidden iframe and calls print on it, so the dialog opens on the one-pager itself. The old behavior printed the whole topic page, which for most topics runs to many browser-rendered pages; the sheets exist precisely so a resident can carry one. Because not every browser lets a script drive an embedded PDF viewer, a short timer opens the sheet in a new tab if printing did not fire, and navigates to it if the popup is blocked, so the button never does nothing. All 197 map entries were verified to point at a PDF that exists on disk, including topics served by a shared sheet, so aortic stenosis and mitral regurgitation both reach the valvular sheet and the three rare infections reach the combined one. The 13 views without a sheet keep the old behavior deliberately (the qr-* pocket cards and the library are already printable pages), as does the QR poster, where the poster is the page. The map is generated, not hand-maintained: gen-qr.py now rebuilds IG_PDF from the manifest alongside IG_GO, so adding a sheet and re-running it keeps the buttons current. The visible labels were changed too, which the first pass missed: the button read "Print Protocol" on 134 topics and plain "Print" elsewhere, so the behavior had changed while the wording still promised the old thing. All 309 buttons now read "Print Infographic", keeping their existing printer icon. The 13 views with no sheet were deliberately left reading "Print", since those fall back to printing the page and labelling them "Print Infographic" would be a promise the button cannot keep. The sheet opens in a new tab only. The first build fell back to navigating the current tab when the browser refused a popup, which under local file mode happened every time and took the reader off the app. It now opens via a synthetic anchor click, which inherits the button's user gesture and is not popup-blocked, and the same-tab path was removed entirely: navigating away unloads the single-page app, so going Back would mean a full reload of a very large document and losing your place in the topic.
- COPD exacerbation: the 6 P’s reconciled, because the page carried THREE different versions. Adding a mimics list surfaced that
copd-exacerbation-management already defined "the 6 P’s" twice more, with different members each time: a triggers table (pneumonia, PE, pneumothorax, pleural effusion, poor compliance, pollution) and a summary tile (pneumonia, pollution, PE, pneumothorax, pump failure, pills). Three lists under one name, on one page, for one disease. The deeper problem was that the triggers list was not a list of triggers. A pulmonary embolism, pneumothorax or effusion does not set off an exacerbation, it is the diagnosis instead of it, so four of those six were mislabeled. Resolution: the page now has exactly one 6 P’s, the alternative diagnoses, being PE, Pneumonia, Pneumothorax, Pump failure, Pulse (ACS or arrhythmia) and Plug or aspiration. The former triggers table is retitled Common Precipitants, keeps its content, and gains a column stating for each entry whether it is a precipitant, the diagnosis itself, or both, since an airway infection precipitates a true exacerbation while an infiltrate means pneumonia rather than AECOPD. The summary tile and the rounds checklist item that called PE a trigger were corrected to match, and sheet #38 was rebuilt on the same six, gaining the previously missing Plug and aspiration entry. PE leads the list as the highest-yield miss: roughly 1 in 6 hospitalized patients with an unexplained exacerbation, pooled 16.1%, with 68% of those emboli in main, lobar or interlobar arteries, so it is not subsegmental noise Aleva, Chest 2017.
- audit.js US-English check extended, and it immediately found more. Three spellings the check did not know were added: the British forms of pheochromocytoma, aluminum and counseling. On the first run the new terms flagged the British form of counseling in four places across index.html and two other sheets that had been there all along, all now corrected. Two implementation notes worth keeping: the terms must be added in the existing
[/regex/i, replacement] array form rather than as objects, and the word-boundary escapes must survive being written to the file, since a first attempt wrote literal backspace characters instead of
- Fixed a CKM card rendering inside the Lipid Management card on the Cardiology rotation page, and added a check so it cannot happen again. The two cards painted on top of each other and the CKM topic was unclickable from that grid. The cause was an insertion anchored on the lipid card's title line rather than on its closing tag: rotation cards come in a compact one-line form and a four-line form, and anchoring on the title is safe for the first and silently nests for the second. The other three grids that list CKM (nephrology, endocrinology, ambulatory) were checked and were correct, and a site-wide scan of all 288 topic cards found no other instance. Every existing check had passed, because the markup was perfectly balanced and structural integrity was intact; the card was simply in the wrong place, which no structural test can see.
audit.js now reports this as a deploy-blocking finding, naming both the outer and inner element, and it rides along on the existing browser render at no added cost. The check was then extended to every card class on the site, not just rotation cards: it now covers all 9,539 card elements across roughly 30 classes, including summary cells, alert boxes, pearl cards, example boxes, trial cards, infographic cards and calculator cards. It flags only a card nested inside another card of the same class, which is always a mistake, while ordinary nesting inside a different container stays silent. Validated by reintroducing the bug, which correctly produced the finding and a failing exit code.
- Every infographic is now US English. A sweep across all sheets found British spellings, UK drug names and UK dosing abbreviations. The drug names were the real problem: a resident searching the toxicology sheet for acetaminophen found nothing, because the sheet used the British name, and one antibiotic was listed under both a drug name and a dosing frequency that do not exist in US practice. Every sheet now uses the US name and US frequency: albuterol, epinephrine, norepinephrine, acetaminophen, succinylcholine, nafcillin, methimazole, amoxicillin-clavulanate, TMP-SMX and BID / TID / QID, plus the whole British spelling set. Genus and species names (Haemophilus, Entamoeba, Neisseria gonorrhoeae), journal titles and angioedema were deliberately left alone.
- audit.js now enforces US English on every deploy. A new HIGH-severity check scans index.html and all infographic sources for UK drug names, dosing abbreviations and British spellings, so this cannot drift back. It strips tags before scanning (a naive pass would rewrite a CSS class name and break the stylesheet), scans script bodies because the pearls and trial database live there, and only suppresses a flagged word when an allowed term physically overlaps it.
- All 189 infographics are now full-page. 14 sheets were leaving up to a third of the page blank and 3 crowded the footer; all now fill the page properly. 56 sheets were rebuilt and now have editable HTML sources, taking the library from 97 sourced sheets to all of them: every sheet in the library now has an HTML source, so no PDF ever has to be patched blind again. All 153 footer QR codes re-verified by machine decode after the rebuild.
- Clinical content corrected on rebuilt sheets. Brain death still listed EEG as an ancillary test, which the 2023 AAN/AAP/CNS/SCCM guideline removed because EEG reads cortex and not brainstem. Cardiogenic shock predated DanGer Shock and ECLS-SHOCK. Anaphylaxis carried UK epinephrine dosing and the UK steroid position. Acute stroke used mmol/L glucose. COPD exacerbation used kPa units.
- Acute pancreatitis expanded on complications, sheet and topic page together: the four Revised Atlanta collections (APFC, pseudocyst, ANC, walled-off necrosis), infected necrosis with PANTER and POINTER, abdominal compartment syndrome, splanchnic vein thrombosis, splenic artery pseudoaneurysm and disconnected pancreatic duct syndrome. The topic page also had a real error corrected: the pseudocyst row still gave the obsolete "> 6 cm" size threshold as a drainage indication.
- SIADH: added why the uric acid is low (proximal urate reabsorption is coupled to sodium, which the volume expansion of water retention switches off), and removed the duplicated Diabetes Insipidus section, which has had its own full topic for some time.
- Famous Cases: every answer now shows the person. All 8 reveal boxes carry a portrait (Phineas Gage daguerreotype with the tamping iron, JFK's White House portrait, the Ramsay coronation portrait of George III, the David portrait of Napoleon, the Stieler Beethoven, FDR's 1944 color portrait, Bob Marley on stage in Zurich 1980, and the Bristol statue of Henrietta Lacks, since no verified freely licensed photograph of her exists). Images are lazy-loaded inside the hidden answer box so nothing spoils the diagnosis before the reveal, and Creative Commons photos carry their required attribution. Cases also reordered most-famous-first: leading with instantly recognized figures hooks attention early, which is what makes the diagnosis stick.
- Infographic fill pass: 37 sheets enriched, and one was outdated rather than merely sparse. A measurement of all 154 PDFs found every sheet passing the one-page check but 44 sitting in the sparse 700-729 band, leaving the lower third bare. Seven are now filled. Pulmonary embolism (#40) was the important one: it had no mention of the 2026 AHA/ACC guideline and still used the "massive / submassive" language that guideline retires. Rebuilt from the official at-a-glance around the Acute PE Clinical Categories A to E with subcategories, the disposition rules (Category A goes home from the ED, C to E are admitted), and three things that were entirely absent: systemic thrombolysis is Class 3 HARM in Categories A1-C2, PERT activation is Class 1 for C-E, and LMWH is now recommended over unfractionated heparin. The other six gained the numbers a resident would otherwise have to look up: IV antihypertensive doses (hypertensive emergency), CHA₂DS₂-VASc components and DOAC dosing with the renal cutoffs (AF with RVR), antianginal doses including the ranolazine-diltiazem cap (chronic coronary disease), D50 / D10, glucagon and octreotide dosing (hypoglycemia, which previously said only "intravenous dextrose"), and expected increments per product (transfusion: 1 unit of red cells raises Hb about 1 g/dL, and a failed increment is a finding rather than an inadequate dose). Every overshoot was resolved by cutting duplicated content first, never a safety item. All 154 remain single-page with 154/154 QRs verified. A second batch added the numbers behind interventions the sheets already named: the water-soluble contrast protocol (100 mL, film at 8 and 24 h, contrast reaching the colon predicts resolution) and neostigmine 2 mg IV with atropine at the bedside for Ogilvie syndrome; STOP-BANG risk bands and the 4 h on 70% of nights adherence standard in OSA; tranexamic acid within 3 h (CRASH-3), 7-day seizure prophylaxis, and anticoagulant reversal in raised ICP; dexamethasone dosing and catheter-related thrombosis management in SVC obstruction; and two safety facts in oncologic emergencies, that rasburicase is contraindicated in G6PD deficiency and that tocilizumab treats CRS but not ICANS and may worsen it. A third batch added nebulized tranexamic acid dosing (hemoptysis), thiamine 200-300 mg before any carbohydrate with the 10 and 5 kcal/kg starting rates (refeeding), perioperative DOAC and warfarin holds with the do-not-bridge rule from PAUSE and BRIDGE (VTE), when a steroid taper is and is not needed (corticosteroids), and the QTc-stacking and linezolid MAO-inhibitor cautions (antibiotic safety). A fourth batch supplied doses for interventions the sheets named but never quantified: heparin 80 units/kg bolus then 18 units/kg/h (acute limb ischemia, where the omitted bolus is the part that matters), isotonic saline at 1-1.5 mL/kg/h before and after contrast plus the point that metformin is a lactic-acidosis question, not a kidney one (contrast nephropathy), platelet transfusion thresholds of 10, 20, 50 and 100 (pancytopenia), vancomycin and ceftriaxone dosing with the reminder that antibiotics alone do not cure a septic joint (septic arthritis), and procainamide dosing with its three stop rules plus correct adenosine technique (tachyarrhythmia). A fifth batch added antidote and rescue doses that the sheets named but never quantified: cyproheptadine 12 mg then 2 mg every 2 h, dantrolene and bromocriptine (NMS and serotonin syndrome), infliximab 5 mg/kg or cyclosporine 2 mg/kg/day at the day-3 decision (acute severe colitis), terlipressin 1 mg every 6 h escalating at day 3, with oxygen saturation as the dose-limiting toxicity (hepatorenal syndrome), starting pressor doses (shock), and the four reversal-agent doses including andexanet low versus high dosing and protamine 1 mg per 100 units (anticoagulation). A sixth batch was chosen by measuring drug-name-to-dose ratio rather than by fill alone, which surfaced the sheets where agents were named but never quantified. Neutropenic fever listed nine antibiotics and zero doses despite a 60-minute clock, and now carries cefepime 2 g q8h, piperacillin-tazobactam 4.5 g q6h and meropenem 1 g q8h, plus the point that vancomycin is not routine and needs a specific indication. Cellulitis gained doses by phenotype, acute liver failure the full NAC regimen with the note that it helps in non-acetaminophen failure too, HIV the CD4 prophylaxis thresholds, and heat stroke the fact that antipyretics and dantrolene do not work because the hypothalamic set point is normal. A seventh batch targeted threshold sheets rather than drug sheets, since dose-count no longer identified the gaps. Added the tube and line positions (endotracheal tip 5 ± 2 cm above the carina, moving 2 cm with neck flexion; central tip at the cavoatrial junction) and the caution that cardiothoracic ratio only applies to a PA film, not the AP portable most inpatients get; numbers behind AEIOU with the point that refractoriness rather than the number decides dialysis; the disease-specific hospice criteria behind the 6-month prognosis; the Gurd criteria, which were absent from the fat embolism sheet entirely; and the three numbers separating RTA types, where type 4 is given away by a high potassium with a urine pH below 5.5. Sparse sheets are down from 44 to 8 and the median fill from 761 to 771.1. The final 8 were then audited one by one and deliberately left alone, because they turned out to be complete rather than sparse: immunotherapy toxicity, nutrition in critical illness, chest pain, pulmonary nodule, burns, cardiac tamponade, hypothermia and drowning, and necrotizing skin infection all already carry the numbers that define them, including the HEART bands with their MACE percentages, the Fleischner 6 and 8 mm thresholds, Parkland 4 mL/kg titrated to urine output rather than to the formula, pulsus paradoxus above 10 mmHg alongside right atrial and right ventricular diastolic collapse, LRINEC with the warning that it supports the diagnosis but does not exclude it, potassium above 12 mmol/L as a stop point with "not dead until warm and dead", and mycophenolate as the second-line agent in checkpoint-inhibitor hepatitis, where infliximab is avoided. They read low only because they are brief, dense topics. Filling them further would have been padding, which the fill rule explicitly forbids. Two measurement lessons were written into the process: low fill and drug-to-dose ratio are screens that say where to look, never evidence that something is missing, and a gap must be confirmed by naming the exact fact and searching for it with tags stripped and case ignored, because two of these sheets looked incomplete only because HTML tags split the phrases being searched for.
- NEW INFOGRAPHIC #154: Outpatient Lipid Management, and two clinical corrections it surfaced. Building the sheet against the official ACC Guideline-at-a-Glance exposed errors already live on the site. (1) The apoB threshold was wrong in 8 places: the site said check apoB when TG > 200, but the 2026 guideline says TG ≥ 150 mg/dL. All corrected. (2) The non-HDL-C goals were missing entirely, despite "LDL-C and non-HDL-C treatment goals are back" being one of the guideline's top take-home messages: < 85 very-high-risk, < 100 high risk or standard ASCVD, < 130 borderline/intermediate. Now on the sheet. The sheet also adds what was absent: the guideline's own CPR framework (Calculate, Personalize, Reclassify), CAC upgraded from Class 2a to Class 1 with the men ≥ 40 / women ≥ 45 rule and the new counting of incidental calcium on non-gated CT, Lp(a) numeric thresholds (≥ 125 nmol/L is ~1.4× risk, ≥ 250 nmol/L is ≥ 2×) with cascade testing and the Class 1 PCSK9 mAb add-on, CKD stage 3-4 added to the treat-regardless-of-LDL list, and monitoring guidance including not checking LFTs or CK routinely. The lipid pages had a One Pager tab but no printable sheet behind it, only the older inline HTML. Built on the 2026 ACC/AHA dyslipidemia guideline: PREVENT risk bands, the numeric LDL goals (< 55 / < 70 / < 100), the five statin indications plus the new early-intervention category, intensity defined by percent reduction rather than milligrams, Lp(a) once per lifetime and apoB when LDL misleads, add-ons as parallel options rather than a ladder, and the situations that change the drug (TG thresholds and the gemfibrozil trap, the nocebo problem behind "statin intolerance", pregnancy stop-list, pitavastatin in HIV, and the rosuvastatin caps in CKD and Asian ancestry). First render passed at 702 pt but left the lower page bare; expanded to 788.8 pt of an 800 pt ceiling, which is what surfaced the omissions above. Library is now 154 sheets, all 154 QRs machine-verified.
- Outpatient Lipid summary tightened. It had grown to 12 cells and roughly 4,000 characters, about double the site norm for a "one-screen" summary. Now 10 cells and about 2,200 characters, 45% shorter, keeping every clinical fact and the reasoning behind it while cutting the padding. The safety-critical cells were deliberately kept (pregnancy stop-list, never gemfibrozil with a statin); what went was the investigational Lp(a) drug pipeline, which changes nothing at the bedside today.
- Search analytics rebuilt to capture failed searches. The
search event previously fired only when someone clicked a result, which meant the most useful signal, the searches that returned nothing, was never recorded. It now fires on the query itself with a results_count parameter, recorded above the no-results branch so both outcomes are captured. It is debounced 1.2 s so a burst of keystrokes produces one event rather than one per letter, ignores queries under 3 characters as noise, and dedupes a held query. The click is now its own search_result_click event, so "what residents looked for" and "what they actually found" are finally separate questions. Verified in-browser: three rapid queries produced a single event, a nonsense query recorded results_count: 0, and a real query recorded 10 results followed by a distinct click event. Note this needs search_term, results_count, topic_id and destination registered as GA4 custom dimensions to be visible; the property currently has none registered, so every custom parameter the site sends is collected and then unqueryable, and registration is not retroactive.
- Page titles now use a pipe separator. Titles were built as
Hyponatremia -3-Step Approach -RoundsRx, and that tight space-hyphen reads like a typo in a search result. All 271 titles in index.html and 251 in the edge function now use Hyponatremia | 3-Step Approach | RoundsRx. The replacement targeted only space-hyphen, so genuine hyphens survived intact: GLP-1, Lung-Protective, 3-Step and Non-Hodgkin are unchanged. Five pieces of runtime code also parsed the old format to build breadcrumbs and share-email subjects, and were updated in the same pass, since otherwise every breadcrumb would have displayed the full title with its suffix still attached.
- SEO: found and fixed the reason 249 of 263 pages were not indexed by Google. Search Console showed 14 pages indexed against 249 not indexed, with 144 "Crawled, currently not indexed" and 98 "Discovered, currently not indexed", and only 30 search clicks in three months. The May 2026 cycle had concluded this was an authority signal rather than a technical fault. That was wrong. Fetching two unrelated live URLs as a crawler sees them showed both serving the same block of oncology topics (oncologic emergencies, pancytopenia workup, chemotherapy toxicities), so every one of the 250 URLs carried a large identical content block, which reads as duplicate content and is exactly what produces those two Search Console states. Cause: the edge function's
stripNonTargetViews() finds each view's end by counting div depth, and five views are missing their own closing tag (the browser silently recovers, a depth counter does not), so those views were never stripped. These were the same MEDIUM "unclosed-tag" findings the audit has reported for months and that were treated as cosmetic because the browser renders fine. Fix: the stripper now clamps every view's range at the next view's start, so a malformed view can no longer swallow its neighbors, with the last view bounded at </main> so the scripts and closing tags survive. Verified against the real file: previously 3 foreign views leaked into every page, now exactly 1 view is served per URL out of 250, roughly 86 KB smaller per page, with an unknown slug still safely returning the full document. A regression guard now runs in audit.js ("SEO view isolation"): it executes the real stripper against six representative URLs, including the first and last views, and fails the deploy if any URL serves more or fewer than exactly one view, if the target view is stripped, or if the document tail is destroyed. It was validated by reintroducing the bug, which correctly produced a HIGH finding and exit code 1. This class of defect was invisible for months because every existing check reads index.html, while the fault lived in the edge function that only crawlers ever see.
- NEW TOPIC: Cardiovascular-Kidney-Metabolic (CKM) Syndrome. A 5-tab page (Staging / Screening / Management / Rounds / Summary) built on the 2026 AHA/ACC/ADA/ASN guideline (JACC, June 9, 2026), verified against the official ACC Guideline-at-a-Glance rather than press coverage. Covers the five stages 0 to 4 with the Stage 3 criteria spelled out (CAC above 100, NT-proBNP ≥ 125 pg/mL with echo dysfunction, very high-risk CKD, or PREVENT 10-year risk ≥ 20%) and the 4a/4b split by kidney failure; the stage-driven screening cadence (annual lipids, glycemia, BP and both eGFR and UACR from Stage 2, FIB-4 every 1 to 2 years for MASLD, pre-HF biomarkers at PREVENT-HF ≥ 5%); and the four CKD drug thresholds that are easiest to get wrong: RAS inhibitor at UACR ≥ 30 with eGFR ≥ 30, SGLT2i at UACR ≥ 200 with eGFR ≥ 20, finerenone added at UACR ≥ 30 despite both with eGFR ≥ 25, and GLP-1 added at UACR ≥ 100 despite both. Every recommendation carries its Class of Recommendation. Deliberately does not restate drug doses, which stay in the Obesity, T2DM and CKD topics and are deep-linked, so there is one place to maintain rather than five. Also captures the two reversals worth knowing: metformin has moved from mandatory first step to a Class 2a glycemic add-on, and BMI alone is no longer adequate without a waist circumference.
- What's New: two 2026 guidelines added. The page had stopped at the March dyslipidemia guideline. Added the 2026 AHA/ACC/ADA/ASN Cardiovascular-Kidney-Metabolic (CKM) Syndrome guideline (JACC, June 9, 2026), which retires and replaces the 2013 AHA/ACC/TOS obesity guideline and reframes obesity, T2DM, CKD and CVD as one syndrome staged 0 to 4, with screening intervals set by stage and a therapy map spanning GLP-1 RA, SGLT2i, RAS inhibitors and finerenone. Also added the first-ever AHA/ACC acute pulmonary embolism guideline (Circulation, March 24, 2026), which retires massive/submassive language for Clinical Categories A to E, discharges Category A from the ED, and recommends PERT activation. Both were verified field by field against the primary publications rather than the press releases.
- Hyponatremia: new iatrogenic section covering mannitol and post-TURP irrigant absorption. Both were missing entirely, and both are traps because the tonicity contradicts the sodium number. Mannitol is an effective osmole, so it causes hypertonic hyponatremia with an osmolal gap, where hypertonic saline is the wrong direction and the fix is stopping the drug; it also flips to hypernatremia in its osmotic-diuresis phase, so the sodium has to be followed both ways. Post-TURP glycine absorption causes genuinely hypotonic hyponatremia with hypervolemia, presenting with hypertension and bradycardia rather than the tachycardia and hypotension you expect intraoperatively, plus two glycine-specific toxicities: hyperammonemic encephalopathy that outlasts the sodium correction, and transient blindness that is the glycine and not a stroke. Includes an irrigant comparison table (glycine, sorbitol, mannitol, saline), why monopolar resection forces an electrolyte-free irrigant at all, why bipolar plus saline has made the syndrome rare, and the spontaneous-overcorrection warning as glycine is metabolized. Both conditions were also placed in the three diagnostic tables where the decision actually gets made, rather than only in their own section: the Step 1 osmolality table now separates post-TURP (hypo-osmolar, swells the brain) from mannitol (hypertonic, do NOT give hypertonic saline), Step 2 gained a fourth volume-status row for acute iatrogenic hypervolemia from post-TURP or operative hysteroscopy irrigant absorption, which is the one hypervolemic hyponatremia that still gets 3% saline, and Step 3 now lists the osmolal gap as a lab to send whenever mannitol or absorbed irrigant is in play.
- Two new pearls (library now 729). "Mannitol causes hypertonic hyponatremia, so hypertonic saline is the wrong direction" (find the osmolal gap, stop the drug, expect the later flip to hypernatremia), and "transient blindness after a TURP is the glycine, not a stroke" (retinal inhibition plus ammonia-driven encephalopathy that outlasts the corrected sodium).
- Corrected-sodium calculator: fixed an inverted term. The output called hyperglycemic hyponatremia "pseudohyponatremia". It is not: glucose genuinely pulls water out of cells and dilutes the sodium (translocational, hypertonic). Pseudohyponatremia is the lab artifact of severe hyperlipidemia or hyperproteinemia, where measured osmolality is normal. A site-wide scan confirmed the other seven mentions already separated the two categories correctly.
- Famous Cases doubled: 8 new cases, 16 total. New additions with portraits: Abraham Lincoln (the Marfan vs MEN2B debate and why each theory has a different fatal complication to screen for), George Washington (acute epiglottitis, the 4 D's, and the junior physician whose tracheotomy call was overruled), Muhammad Ali (Parkinson's vs post-traumatic parkinsonism, and the under-40 Wilson's rule), Stephen Hawking (ALS: UMN + LMN signs without sensory loss, and what actually extends survival), Vincent van Gogh (episodic neuropsychiatric differential plus the digitalis xanthopsia board pearl), Marie Curie (radiation aplastic anemia and the pancytopenia workup), Queen Victoria (X-linked hemophilia B, confirmed by 2009 Romanov DNA analysis), and Typhoid Mary (chronic biliary S. Typhi carriage and quarantine ethics). All portraits are public domain. A Reveal All Answers toggle at the top serves second-pass review: first-timers keep the guess-the-diagnosis format (active retrieval is what makes the cases stick), while returning readers can open all 16 at once and skim.
- Local file mode: images now load. Root-relative image paths (/images, /infographics thumbnails) resolve to the drive root when index.html is opened directly as a local file, so every portrait and thumbnail appeared broken offline. A small shim now rebases those paths onto the folder the file lives in when running under file:, captured before SPA navigation rewrites the URL. Production behavior on roundsrx.com is unchanged.
- Summary tabs: last three bare-directive summaries rewritten. A site-wide scan of all 181 Summary sections found the improvement pass essentially complete, with three stragglers still in the old telegraphic style: Hyponatremia, Hyperkalemia and Hypercalcemia. All three now explain the why behind each move, including the urine-osm-then-urine-Na logic and the overcorrection rescue in hyponatremia, the treat-the-ECG-not-the-number rule and the delayed hypoglycemia after IV insulin in hyperkalemia, and the fluids-first rationale (hypercalcemia causes nephrogenic DI, so every patient arrives volume depleted) plus the FHH surgical trap in hypercalcemia.
- Build stats recounted from source at deploy: 231 topics and tools, 15 rotations, 1,070 pimp questions, 1,803 trial citations, 1,165 alert flags, 569 clinical scenarios, 729 pearls, 189 infographics, 6,179 drug-table entries across 1,103 tables. Four tiles moved: the topic count is now measured rather than estimated (all 249 views minus the 15 rotation indexes and the dashboard, about and What's New pages), and trial, alert and drug-entry counts fell slightly because the removed Quick Reference sections took some with them. The OG image was regenerated to match, since it still advertised 250 topics and 153 infographics.
v5.6 - August 6, 2026
- Pneumonia rebuilt on the 2025 ATS guideline. The update (published Jan 2026) reverses two things: steroids in severe CAP are now a conditional recommendation FOR (2019 suggested against), and in non-severe CAP the recommendation against is now strong. Duration got shorter, not longer: under 5 days with a 3-day minimum once clinically stable for outpatients and non-severe inpatients, while severe CAP keeps a 5-day floor as a strong recommendation. Two new questions were added: a detected respiratory virus in a healthy outpatient with no comorbidity means no antibiotics at all, and lung ultrasound is an acceptable alternative to chest radiography. Applied across the topic page, all four duration statements, the steroid tables, the workup, and the summary tiles, with a "what changed" box and per-row tags.
- Pneumonia one-pager replaced. Series #23 was "Severe CAP", covering only ICU-level disease; it is now Community-Acquired Pneumonia spanning outpatient to ICU, and includes an explicit MRSA / Pseudomonas indications table showing that with risk factors but no prior isolation, non-severe CAP gets cultures and no empiric coverage while severe CAP gets both. Old severe-cap.pdf 301-redirects to the new file; series number preserved so printed QR codes still resolve.
- New Hypokalemia one-pager (#151) covering severity and ECG, the replacement arithmetic, the magnesium/ROMK rule, and the urine K/creatinine workup.
- Potassium replacement arithmetic corrected. The classic "10 mEq raises serum K by 0.1" is a best case, not an average: the real-world inpatient median is 0.05 mEq/L per 10 mEq (0.07 off potassium-affecting drugs, 0.03 on a loop diuretic). One protocols table also claimed "~0.3 mEq/L per 10 mEq", triple the classic rule and six times the observed median. Fixed in all five places, with the Kruse & Carlson and AJHP studies cited.
- Duplicate Electrolyte Replacement pages merged. Two quick-reference pages shared the same title and sat next to each other in the homepage nav. They are now one page with Protocols, Rates & Safety, Sodium, and One Pager tabs, added to the ICU rotation. The retired page 301-redirects, and three dead references (page title, meta description, and a search-index entry pointing at a now-missing view) were removed.
- Hyperkalemia one-pager expanded with a full type 4 RTA section, pseudohyperkalemia, an oral binder comparison, and insulin dosing in renal impairment. Also added to the Emergency Medicine rotation, which previously had no potassium emergency at all.
- US English sweep. ~1,300 replacements across index.html, all 97 infographic sources, and the manifest: spelling, drug names (epinephrine, albuterol, acetaminophen, rifampin, cyclosporine), practice terms (NPO, the OR, labs), and lab units (fibrinogen mg/dL, albumin and hemoglobin g/dL). Eight British PDF filenames renamed with redirects. Journal titles, Haemophilus, angioedema and Leucovorin deliberately left alone.
- Trial database cleanup. Removed four orphaned duplicate entries (ISIS-2, PROVE-IT, PARADIGM-HF, MADIT-II existed under both dash and underscore keys); the stale PARADIGM-HF copy carried the wrong N (8,442 rather than 8,399). Also cleared 33 em-dashes from calculator output and trial verdicts, so index.html now contains none.
- SIADH rebuilt as a full Endocrinology page with new Workup, Management and Medications sections (all three were previously stubs), a causes table, and a new comparisons tab holding SIADH vs diabetes insipidus and SIADH vs cerebral salt wasting. The CSW table covers the trap that low uric acid does not separate them and that fractional excretion of urate only discriminates after the sodium is corrected (normalizes below 11% in SIADH, stays above in CSW), plus the warning never to fluid restrict a hyponatremic SAH patient.
- Four broken pages repaired. Malformed table markup was silently corrupting the DOM: SIADH lost its entire treatment section (fluid restriction, hypertonic saline, tolvaptan and the ODS warning rendered nowhere), and SIADH, ILD and Leukemia had 6 to 7 sections each reparented into the Blood Transfusion Guide by the browser's parser. Also fixed an unclosed table in Lower GI Bleed and a section headed "Sarcoidosis" that actually contained the IPF antifibrotic table. All 1,427 section anchors now resolve to their correct parent view, verified against the source in a live DOM check.
- Infographic Library search added, filtering all 151 cards by name, topic, category or series number with multi-word matching, a live count and collapsing category headings. Also merged a duplicate Haematology / Hematology category that had been rendering two identical headings and splitting the sheets between them.
- Build stats recounted from source: 249 topics and tools, 15 rotations, 727 pearls, 1,074 pimp questions, 1,859 trial citations, 1,168 alert flags, 28 calculators, 566 clinical scenarios, 151 infographics, and 202 trial database entries. OG image regenerated.
v5.5 - July 30, 2026
- Infographic Library expanded to 150, up from the 56 that shipped in v5.4. The library index is now verified complete in all three directions: 150 PDFs on disk, 150 cards, 150 distinct assets referenced, with no card pointing at a missing file, no file left uncarded, and nothing embedded in a topic that is not also in the library. 145 of 202 topic views now embed an infographic under the One Pager tab. Eight infographics currently live in the library only, without a parent topic embed: common ICU infections, HAP/VAP, antibiotic safety, ventilator weaning and SBT, raised ICP/TBI, nutrition in critical illness, tracheostomy emergencies, and endocrine emergencies.
- Infographic Library headline corrected, it previously claimed that every infographic was also embedded in its parent topic under the One Pager tab. That is true for 142 of 150, not all of them, so the sentence now reads "most" rather than "each one."
- Palliative Extubation: cross-topic template residue removed. Three blocks of pulmonary embolism content had been copied into the Rounds section of the palliative extubation view: an "Escalation Triggers / Activate PERT" alert calling for troponin and BNP trending, repeat echo for RV function, and vasopressor escalation; a "Transition to Oral Anticoagulation" block with full DOAC and warfarin bridging doses; and a "Follow-Up After Discharge" block covering CTEPH screening, thrombophilia workup, and age-appropriate cancer screening. On a comfort-care withdrawal page this was clinically wrong, and the escalation block directly contradicted the same page's own guidance a few lines above it, which correctly instructs you to remove SpO₂, BP, and HR displays because the goal is comfort rather than survival or physiologic targets. All three blocks were self-contained sections, so removal was a clean excision. Div structure verified balanced and the pre-deploy audit passes clean.
- Build stats refreshed and recounted from source: 250 topics and tools, 15 rotations, 727 pearls, 1,068 pimp questions, 1,857 trial citations (up from the 1,771 shown since v5.4), 1,161 alert flags, 28 calculators, 566 clinical scenarios, 150 infographics, and 6,050 drug-table entries across 1,079 tables. Two new cells added to the Build Stats grid, Clinical Pearls and Infographics, neither of which had been surfaced there before. Also corrected the About intro, which read "245 clinical topics and tools" while the stats grid directly below it said 250.
- Dashboard rotation topic counts recounted, every rotation card except Palliative Care was understating its own size, in some cases badly. Each count is now derived from the topic cards actually listed inside that rotation view: ICU 23 to 26, Cardiology 16 to 25, Pulmonology 10 to 14, Gastroenterology 12 to 19, Nephrology 11 to 14, Infectious Disease 12 to 22, Neurology 9 to 11, Emergency Medicine 11 to 16, General Wards 10 to 33, Hematology/Oncology 19 to 24, Endocrinology 16 to 17, Ambulatory 23 to 25, and Rheumatology corrected downward from 10 to 8. General Wards is the largest because it deliberately reuses cross-cutting topics (sepsis, CAP, AKI, hyperkalemia) that also live under their own specialty rotations, so the 282 total across all rotation cards counts shared topics more than once by design.
- OG image regenerated with a fourth stat, 150 Infographics, alongside 250 topics, 15 rotations, and 1,068 pimp questions. Stats row went from a 3-column to a 4-column flex layout with the gap reduced from 120px to 90px to stay inside the 1040px content width.
- Metadata and freshness pass: the "240 evidence-based protocols" claim was corrected to 250 in all five places it appeared (og:description, twitter:description, JSON-LD description, the Netlify edge function's dashboard description, and the PWA manifest). Structured-data
dateModified and lastReviewed refreshed to 2026-07-30 in both the static head block (was 2026-05-01) and the dynamic per-topic block (was 2026-03-07). Sitemap lastmod updated only for the pages that actually changed this cycle (home, About, palliative extubation, infographic library) rather than blanket-bumping all 248 URLs, since lastmod should reflect real edit dates. Service worker cache bumped to roundsrx-v15 so returning users pick up this build instead of a cached copy.
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 labs, 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: September 7, 2026 at 10:57 AM