Orientation Feedback for Tension Pneumothorax

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.  

In this case, a 65-year-old man is brought to the emergency department by ambulance because of acute chest pain and respiratory distress. From the chief complaints, the differential diagnosis is broad; however, the comprehensive history narrows the differential. The patient had an acute onset of right-sided chest pain 10 minutes before the ambulance arrived. He rates the pain as an 8 on a 10-point scale. The pain is excruciating, sharp, and increases with respiration. 
 
The patient appears pale and in marked respiratory distress. He is moaning and holding his hands over the right side of his chest. Vital signs show tachypnea, tachycardia, and low blood pressure. Physical examination shows no breath sounds; there is tracheal deviation, jugular venous distention, hyperresonance to percussion on the right side of the chest, faint heart sounds, and weak peripheral pulses. The skin is pale, cool, and diaphoretic. The remainder of the physical examination is unremarkable. The patient's illness, at this point, seems most consistent with an intrathoracic process.

The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case.  

An ideal approach that would result in the highest performance for this case would include: 

• Performing a targeted physical examination, including all of the following examinations: 
  • Chest/lung 
  • Cardiovascular 
• Cardiac monitoring
• Assessing oxygen saturation by pulse oximetry
• Performing a needle thoracostomy for decompression as soon as the absent breath sounds and exam findings consistent with tension pneumothorax are discovered
• Ordering a chest tube insertion for lung reexpansion following the needle thoracostomy
• Confirming appropriate tube placement and lung reexpansion with a chest x-ray
• Monitoring the patient’s blood pressure and respiratory rate until the patient’s condition has stabilized

In this acute presentation, timing is critically important. An ideal approach would include completing the above diagnostic and management actions as quickly as possible, as timely diagnosis and management are essential in this case. Treatment should be initiated immediately before the patient’s condition worsens.

Examples of actions that would lower your score include: 

• Failure to examine the chest
• Admission before treatment 
• Failure to order a chest x-ray after inserting the chest tube and/or needle thoracostomy 
• Delay in treatment to reexpand the lung, or absence of treatment
• Sending the patient home before or without treatment
• Ordering anything that might delay treatment (eg, a 12 lead ECG, arterial blood gases, or a portable chest x-ray) if ordered before the patient’s condition is stabilized
• Delaying diagnosis or treatment and pursuing alternative diagnoses with tests such as a lung scan will waste valuable time and could be harmful or even fatal to the patient
• Ordering any invasive or noninvasive actions that would subject the patient to unnecessary discomfort or risk or would add no useful information to that available through safer or less invasive means, for example: 
  • CT before lung re-expansion
  • Endotracheal intubation
  • Pulmonary function testing
  • Thrombolytic therapy

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient and would not impact your score include:

• Analgesics
• Bronchodilators
• Complete blood count
• Electrolytes
• Intravenous fluids

Orientation Feedback for Rheumatoid Arthritis

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.  

In this case, a 32-year-old woman comes to the office because of knee pain and swelling. From the chief complaint, the differential diagnosis is broad. It includes osteoarthritis, infectious arthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), gout, and psoriatic arthritis. The comprehensive history, however, narrows the differential. The patient has experienced increasing fatigue and generalized weakness during the past 4 months. She developed generalized aches and morning joint stiffness during the past 8 weeks and, more recently, pain and intermittent swelling of both wrists, and of the proximal metacarpophalangeal joints, as well as bilateral knee swelling. These signs and symptoms are highly suggestive of a chronic systemic inflammatory process.  

Physical examination shows bilateral swollen, warm, and tender wrist, proximal metacarpophalangeal, and knee joints, and bilateral knee effusions. Other physical findings are unremarkable. In the absence of other findings, the patient’s illness, at this point, would seem most consistent with rheumatoid arthritis. While the presence of certain clinical features is helpful in excluding other connective tissue diseases and osteoarthritis, further diagnostic evaluation is appropriate to confirm the presumptive diagnosis and establish the severity of the disease.

The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case.  

An ideal approach that would result in the highest performance for this case would include:

• Performing a targeted physical examination, including all of the following examinations: 
  • Extremities/spine
  • Chest/lung
  • Cardiovascular
  • Abdominal
  • Skin
  • HEENT/neck
  • Lymph node 
• Ordering a rheumatoid factor test or a cyclic citrullinated peptide antibody (Anti-CCP) test to support the diagnosis of rheumatoid arthritis
• Ordering a combination of nonsteroidal anti-inflammatory drug (NSAID) or corticosteroids to relieve pain and inflammation for interim relief, with a disease-modifying antirheumatic drug (DMARD), which prevents or slows joint damage, for comprehensive therapeutic treatment

The diagnostic workup should also include:

•  A complete blood count
• Arthrocentesis with relevant synovial fluid studies (cell count, crystals, and bacterial culture)
• Antinuclear antibody assay
• Erythrocyte sedimentation rate or C-reactive protein test to assess the severity of the disease
• Joint x-rays to provide a baseline assessment

In adult patients, an ideal approach to treatment would focus on decreasing inflammation, preventing or slowing joint damage, and improving function. It is important to manage the acute phase of the disease and to address the long-term care of the patient in this case.

The management workup should also include: 

• Advising the patient to exercise appropriately to prevent deformity and loss of joint function or referring to physical or occupational therapy

While many case scenarios run for a relatively short period of simulated time, a matter of hours or days, this scenario runs for a longer period of time, weeks. This illustrates the importance of allowing sufficient time for the patient to respond to treatment and emphasizes monitoring and long-term management.

Examples of actions that would lower your score include:

• Any delay in diagnosis
• Treatment with NSAIDs or corticosteroids alone
• Failure to order any physical examination
• Failure to obtain appropriate diagnostic studies
• Failure to treat rheumatoid arthritis
• Treatment with biologic agents alone, such as adalimumab, since they are not first line treatment of rheumatoid arthritis and would not act to control symptoms in the short term
• Use of opioids due to concerns about opioid overuse
• Ordering any invasive or noninvasive actions that would subject the patient to unnecessary discomfort or risk or would add no useful information to that available through safer or less invasive means, for example: 
  • Arthroscopy
  • Synovial biopsy

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient and would not impact your score include:

• Chlamydia trachomatis tests
• Neisseria gonorrhoeae tests
• Thyroid studies
• Urinalysis
• Uric acid, serum

In this case simulation, when NSAID or corticosteroid treatment is initiated, the patient reports both joint and systemic improvements. Therefore, ordering a rheumatology consult or additional monitoring is appropriate but optional during the time frame of this simulation. 
 

Orientation Feedback for Ascending Aortic Dissection 

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.

In this case, a 65-year-old woman comes to the emergency department because of chest pain. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows the differential. The patient is experiencing sharp, left-sided chest pain that radiates to her left jaw and to her back. The pain began abruptly 45 minutes before the patient came to the emergency department. She is now short of breath and mildly nauseated. She has a history of hypertension for the past 5 years that is being appropriately treated with medication. There is no history of any previous episodes of chest pain either at rest or on exertion. The absence of fever, chills, cough, or pleural rub suggests that the problem is not an infectious pulmonary process.

Physical examination shows hypertension and tachycardia with bounding central and peripheral pulses. The patient is anxious, diaphoretic, and in severe distress from chest pain. Cardiovascular examination reveals a prominent and sustained apical impulse, and an indistinct S2 with S4 audible at the apex, and a grade 2/6 diastolic decrescendo murmur heard best at the right sternal border. HEENT/neck examination shows grade II arteriovenous nicking on funduscopic examination. The remainder of the physical examination is unremarkable. The patient’s illness, at this point, would seem most consistent with a coronary or aortic abnormality with associated aortic regurgitation. In this case, the sudden onset of radiating chest pain along with the bounding pulses, widened pulse pressure, aortic murmur, and long history of hypertension are highly suggestive of the diagnosis of ascending aortic dissection.

The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case.

An ideal approach that would result in the highest performance for this case would include: 

• Performing a targeted physical examination including all of the following examinations: 
  • Cardiovascular
  • Chest/lung
  • Neurologic/psychiatric 
• Ordering a 12-lead electrocardiography (ECG)
• Ordering a portable chest x-ray
• Stabilizing the patient with an intravenous (IV) beta-blocker to lower both blood pressure and heart rate
• Administration of an IV narcotic analgesic to alleviate pain
• Monitoring the patient’s cardiovascular status with a cardiac monitor or by ordering repeat vital signs
• Ordering some measure of oxygen saturation 
• Once stable, ordering some form of chest imaging that would assess for an aortic dissection including one of the following:
  • Computed tomography (CT) of the chest with contrast
  • Cardiac computed tomography angiography (CTA) with contrast
  • Echocardiograph
  • Transesophageal echocardiography (TEE)
  • Magnetic resonance imaging (MRI) of the chest
  • Cardiac MRI with gadolinium
• Once the ascending aortic dissection is discovered and aortic root involvement confirmed, treating by ordering one of the following:
  • Open heart surgery
  • Endovascular aortic aneurysm repair (EVAR)
  • Thoracotomy or cardiothoracic surgery
  • General surgery consult

The diagnostic workup should also include: 

•  Blood tests for serum creatinine (basic metabolic profile or complete metabolic profile) to assess kidney function
• Electrolytes to check sodium and potassium concentrations 
• A complete blood count (CBC) to look for signs of anemia
• Serum creatine kinase or serum troponin I (cardiac enzymes) to rule out myocardial compromise
• A blood type and crossmatch

In this acute presentation, timing is critically important. An ideal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first 2 hours of simulated time).

Examples of actions that would lower your score include:

• Failure to order any physical examination
• Failure to order an imaging study that would reveal the dissection
• Failure to administer an antihypertensive agent
• Failure to order surgical intervention
• Ordering other IV Antihypertensives without an IV Betablocker
• Ordering Antihypertensives other than IV route of administration
• Neglecting to order indicated blood tests
• Delay in diagnosis or treatment
• Ordering anything unnecessary that would waste time, even if the test or procedure were not invasive or risky (eg, lung scan)
• Ordering any invasive or noninvasive actions that would subject the patient to unnecessary discomfort or risk or would add no useful information to that available through safer or less invasive means, for example:
  • Changing the patient’s location to the outpatient office or sending the patient home 
  • Ordering a chest tube
  • Ordering exercise ECG
  • Administering heparin
  • Ordering laparotomy
  • Ordering needle thoracostomy
  • Ordering a stress echocardiography
  • Administering thrombolytics
  • Administering warfarin

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient and would not impact your score include:

• Admitting the patient to the inpatient ward or intensive care unit
• Administering antibiotics

Orientation Feedback for Asthma

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.

In this case, a 4-year-old boy is brought to the office because of increasing shortness of breath during the past 3 days. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient has been wheezing and has a cough that has been worsening. The mother says that the wheezing seems to get worse after the patient plays outside but resolves shortly after he comes inside. The patient has a history of frequent episodes of “wheezy bronchitis” and ear infections. When the patient was 2 years old, he was hospitalized for 1 week for similar symptoms and treated with intravenous antibiotics and oxygen. At age 18 months, the patient had pressure equalizing tubes inserted. The patient also has a history of allergy to pollen and atopic dermatitis.

Physical examination shows slight tachycardia. Chest/lung examination reveals bilateral, mild, intercostal retractions, and bilateral expiratory wheezes with prolonged expiratory phase, and no crackles. HEENT/neck examination shows pale, boggy, edematous nasal mucosa without nasal flaring. Skin examination reveals dry, scaly patches in the antecubital areas. These physical exam findings in the setting of increased coughing and wheezing, as well as the history of frequent respiratory and ear infections, are highly suggestive of the diagnosis of asthma.

The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. 

An ideal approach that would result in the highest performance for this case would include: 

• Performing a targeted physical examination, including all of the following examinations:
  • HEENT/neck
  • Chest/lung
  • Cardiovascular
  • Abdominal 
• Addressing oxygen status by ordering pulse oximetry or oxygen therapy 
• Treating the patient’s asthma with inhalation bronchodilators (such as albuterol or levalbuterol with ipratropium)
• Administering an oral (PO) steroid

The management workup should also include:

• Counseling the patient/family about asthma care and the side effects of medication
• Monitoring the patient’s respiratory status by ordering a repeat chest/lung examination after treatment 

In this acute presentation, timing is important. An ideal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first few hours of simulated time).

Examples of actions that would lower your score include:

• Administering a bronchodilator by a non-inhalation route (such as intramuscular or oral)
• Administering a less effective bronchodilator (such as ipratropium alone)
• Monitoring the patient by ordering invasive testing such as arterial blood gas analysis instead of ordering chest/lung examination after treatment
• Failing to counsel the patient/family
• Any delay in diagnosis or treatment
• Failure to order a physical examination
• Failure to administer a bronchodilator
• Failure to address the patient’s oxygen status
• Ordering any invasive or noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, for example: 
  • Administering antibiotics
  • Ordering a bronchoscopy
  • Ordering a chest CT
  • Ordering endotracheal intubation
  • Administering intravenous sympathomimetics

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient and would not impact your score include:

• Antihistamines
• Antitussives or expectorants 
• Pulmonary function tests 
• Vaccines

Orientation Feedback for Diabetes with ketoacidosis; E. coli  sepsis   

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.

In this case, a 31-year-old woman is brought to the emergency department by her roommate because of lethargy, nausea, and vomiting. From the chief complaints, the differential diagnosis is broad and includes the many causes of acutely altered mental status. However, the comprehensive history narrows the differential, making uncontrolled diabetes very likely. The patient has been experiencing nausea and vomiting for the past 24 hours and has been unable to eat during that time. During the past hour, she has become drowsy and lethargic. She has a history of type 1 diabetes mellitus, for which she normally takes insulin multiple times daily. However, she has had no insulin during the past 24 hours. The patient’s roommate says that the patient experienced some chills yesterday.

The patient appears drowsy, lethargic, and acutely ill. Physical examination reveals elevated temperature, tachypnea, tachycardia, and hypotension. Cardiovascular examination shows thready central and peripheral pulses. Skin examination reveals poor turgor. HEENT/neck examination shows dry mucous membranes. Abdominal examination reveals diffuse mild tenderness without guarding, rebound, or masses. Neurologic/psychiatric examination shows that the patient is lethargic but oriented. Taken together, the history and physical examination findings support the initial impression of complications of type 1 diabetes mellitus. In this particular patient, the history of type 1 diabetes mellitus presenting with prolonged nausea and vomiting and lethargy and drowsiness, combined with the physical examination findings of fever, thready pulses, tachycardia, signs of dehydration, and diffuse abdominal tenderness are highly suggestive of the diagnosis of diabetic ketoacidosis due to infection and inadequate insulin.

The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case.

An ideal approach that would result in the highest performance for this case would include:

• Performing a targeted physical examination, including all of the following examinations:
  • Chest/lung
  • Cardiovascular
  • Abdominal
  • Neurologic/psychiatric 
• Assessing the glucose level by ordering a blood glucose test using a glucometer
• Assessing for signs of infection by ordering a complete blood count (CBC) and urinalysis
• Stabilizing the patient with isotonic intravenous (IV) fluids (eg, Lactated Ringer solution or normal saline solution) 
• Treating the patient empirically with a broad-spectrum IV or intramuscular (IM) antibiotic to cover the most likely sources of infection 
• Once the serum glucose result is obtained, treating the hyperglycemia with IV insulin 
• Monitoring the patient’s cardiovascular status by ordering repeat vital signs or by changing the patient’s location to the inpatient unit or intensive care unit

The diagnostic workup should also include:

• Assessing for acidosis by ordering an arterial blood gas 
• Identifying the organism by ordering a bacterial blood culture and urine culture before administering empiric antibiotics
• Assessing potassium level with serum electrolyte measurements
• Evaluating for presence of ketones with either a serum beta-hydroxybutyrate or urinalysis
• Assessing kidney function by ordering a serum creatinine or urea nitrogen measurements (basic metabolic profile or complete metabolic profile) 
• Continued monitoring of the patient’s serum glucose, electrolytes (particularly potassium), and arterial blood pH after treatment

In this acute presentation, timing is critically important. An ideal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first hour of simulated time).

Examples of actions that would lower your score include: 

• Any delay in diagnosis or treatment
• Administering IV fluids other than isotonic solutions (eg, hypotonic saline solutions or dextrose in water)
• Treating initially with subcutaneous (SQ) insulin instead of IV insulin
• Administering inappropriate antibiotics
• Neglecting to order appropriate blood tests
• Ordering unnecessary tests or procedures that would serve no clear diagnostic or therapeutic purpose even if those actions are unlikely to cause harm or are low risk
• Failure to order any physical examination
• Failure to order a serum glucose test
• Failure to order a blood culture before administering empiric antibiotics
• Failure to treat with IV fluids
• Failure to administer antibiotics
• Failure to administer insulin
• Failure to adequately monitor the patient after treatment.
• Ordering any invasive or noninvasive actions that would subject the patient to unnecessary discomfort or risk or would add no useful information to that available through safer or less invasive means, for example: 
  • Gastric lavage
  • Upper gastrointestinal endoscopy

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient and would not impact your score include:

• Antiemetics 
• Proton pump inhibitors 
• Lumbar puncture 
• Abdominal imaging 
• Antipyretics 
• Oxygen 
• 12-lead or rhythm electrocardiography

Orientation Feedback for Eclampsia

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.

In this case, a 25-year-old woman at 38 weeks’ gestation comes to the emergency department after suffering a seizure with loss of consciousness about 10 minutes earlier. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows the differential. The patient is gravida 1, para 0, and has been receiving routine prenatal care. The pregnancy has been uncomplicated so far except for a severe headache during the past 3 days, and her feet have appeared swollen during the past 2 to 3 weeks. She has no previous history of seizures, and there is no history of hypertension or renal or neurologic disease. The patient is conscious but appears confused.

Physical examination shows tachycardia, a low-grade fever, and elevated blood pressure. Cardiovascular examination shows a loud S4 and bounding central and peripheral pulses. There is a grade 2/6 systolic ejection murmur at the left sternal border without radiation. There is marked vasospasm on funduscopic examination with normal disc margins and a minor tongue laceration. Abdominal examination shows a gravid uterus with a fundal height of 37 cm. Estimated fetal weight is 2700 g (6 lb). The fetus is cephalic by palpation with a fetal heart rate of 144 beats/min. Genital examination reveals an edematous vulva. The cervix is dilated to 1 cm and 50% effaced. Extremities/spine examination shows 4+ pitting edema in both lower extremities to the mid-thigh region. Neurologic/psychiatric examination shows that the patient is conscious but oriented to person and place only. Deep tendon reflexes are 4+ with bilateral clonus at the ankles. The remainder of the physical examination is unremarkable. The patient's illness, at this point, would seem most consistent with a neurologic or cardiovascular abnormality, possibly pregnancy-associated. In this pregnant patient, the new onset of seizure, elevated blood pressure, lower extremity edema, and hyperactive reflexes at this point, would be most consistent with the diagnosis of eclampsia.

The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case.

An ideal approach that would result in the highest performance for this case would include: 

• Performing a targeted physical examination, including all the following examinations:
  • Skin
  • HEENT/neck
  • Chest/lung 
  • Cardiovascular
  • Abdominal
  • Genital
  • Extremities
  • Neurologic/psychologic
• Ordering a complete blood count (CBC) to rule out hemolysis
• Stabilizing the patient with intravenous (IV) magnesium sulfate to prevent another seizure
• Administering an ideal antihypertensive (IV hydralazine or IV labetalol or PO nifedipine) to control blood pressure
• Once the patient’s condition is stabilized, delivering the fetus either by stimulating contractions using ideal uterotonics, by performing a cesarean delivery, or by consulting obstetrics/gynecology 
• Ordering fetal monitor to watch fetal heart rate until delivery 
• Measuring the patient’s urine output 

The diagnostic workup should also include:

• Assessing kidney function by ordering serum creatinine or urea nitrogen (basic metabolic profile or comprehensive metabolic profile)
• Checking sodium and potassium levels by ordering electrolytes
• Ordering liver enzymes and platelet count to diagnose HELLP syndrome
• Assess for proteinuria by ordering a urinalysis 

In this acute presentation, timing is critically important. An ideal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first hour of simulated time).

Examples of actions that would lower your score include:

• Ordering a peripheral blood smear instead of a complete blood count to rule out hemolysis
• Administering intramuscular (IM) or intravenous (IV) phenobarbital or benzodiazepine instead of IV magnesium sulfate
• Administering any IV antihypertensive other than (IV hydralazine or IV labetalol or PO nifedipine)
• Stimulating contractions using less effective uterotonics
• Failure to monitor the patient’s urine output
• Any delay in diagnosis or treatment
• Failure to order a neurologic/psychiatric examination
• Failure to administer an antihypertensive agent
• Failure to monitor the fetus or mother
• Ordering any invasive or noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, for example: 
  • Changing the location to the outpatient office or sending the patient home
  • Administering mifepristone PO
  • Ordering CT, abdomen/pelvis
  • Administering carboprost IM
  • Ordering a dilatation and curettage

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient and would not impact your score include: 

•  Arterial blood gases or Pulse oximetry
• Fibrin breakdown products
• Thrombin time, plasma