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Orientation Feedback for Tension Pneumothorax In evaluating case performance, the domains of diagnosis (including physical exam 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. Initially the presentation and reason for visit suggest a broad differential diagnosis, but the limited available 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 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 and 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 a pulmonary 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. Timely diagnosis and management is essential in this case. An optimal, efficient, and effective diagnostic approach would include quickly performing a targeted physical exam that includes chest/lung and cardiovascular examination, cardiac monitoring, and assessing oxygen saturation with a pulse oximetry. Treatment should be initiated immediately before the patient’s condition worsens. Ordering anything that might delay treatment, eg, a 12-lead ECG, an arterial blood gas, or a stat, portable chest x-ray would be suboptimal in this case if ordered before the patient’s condition is stabilized. As soon as the absent breath sounds are discovered, optimal treatment would include inserting a needle thoracostomy followed by a chest tube insertion or a surgical consultation. A chest x-ray should be ordered to confirm appropriate tube placement and lung re-inflation. The patient’s blood pressure and respiratory rate should be closely monitored until the patients condition has stabilized. Ordering analgesics or intravenous fluids is appropriate but optional during the time frame of the simulation if appropriate primary management is quickly instituted. Examples of additional tests and treatments that could be ordered but would be neither useful nor harmful to the patient include: Angiography after treating the pneumothorax Bronchodilators Cardiac enzymes after treating the pneumothorax

Delaying diagnosis or treatment and pursuing alternate diagnoses with tests such as a lung scan will waste valuable time and could be harmful or even fatal to the patient. An optimal approach would include completing the above diagnostic and management actions as quickly as possible. admission before treatment.Complete blood count Electrolytes Examples of suboptimal management of this case would include ordering a complete physical examination and delay in expansion of the lung. timing is critically important. failure to order a chest x-ray after inserting the chest tube and or needle. and long delay in treatment. In this acute presentation. Other examples of treatments that would waste time. Examples of poor management would include failure to examine the chest. subject the patient to unnecessary discomfort or risk. and add no real benefit to this patient include: Angiography before treating the pneumothorax Cardiac enzymes before treating the pneumothorax CT before lung reinflation Intubation Pulmonary function testing Thrombolytic therapy .

subtract from. a 32-year-old woman comes to the office because of knee pain and swelling. and location are considered. the differential diagnosis is broad. and lymph node examinations). monitoring. The patient has experienced increasing fatigue and generalized weakness during the past 4 months. abdominal. it is not feasible to list every action that might affect an examinee's score. an optimal approach to treatment would focus on relieving pain. chest. proximal metacarpophalangeal joints. joint x-rays would provide a baseline assessment. Other physical findings are unremarkable. is considered optimal in . and knee joints. In the absence of other findings. In this case. gout. timing. or have no effect on an examinee's score for this case. From the chief complaint. at this point. e. An optimal.. In adult patients. narrows the differential. reducing inflammation. the patient would be advised to exercise appropriately. and bacterial culture). warm. therapy. or reactive arthritis. Physical examination shows bilateral swollen. the patient’s illness. The comprehensive history. It includes osteoarthritis. and improving function. Therefore. A rheumatoid factor test or a cyclic citrullinated peptide antibody (Anti-CCP) test would support the diagnosis of rheumatoid arthritis. rheumatoid arthritis. the domains of diagnosis (including physical exam and appropriate diagnostic tests). HEENT. These tests serve to assess the severity of the disease and consider the likelihood of SLE. The diagnostic workup would also include a complete blood count. an antinuclear antibody (ANA) test. further diagnostic evaluation is appropriate to confirm the presumptive diagnosis and establish the severity of the disease. preventing or slowing joint damage. In addition. efficient. arthrocentesis with relevant synovial fluid studies (cell count. proximal metacarpophalangeal. The computer-based case simulation database contains thousands of possible tests and treatments. While the presence of certain clinical features is helpful in excluding other connective tissue disease and degenerative joint disease (osteoarthritis). gout. pain and intermittent swelling in both wrists. methotrexate or etanercept. seems most consistent with rheumatoid arthritis. however. A nonsteroidal anti-inflammatory drug (NSAID) or corticosteroid is considered first-line therapy for relieving pain and reducing inflammation.g. and psoriatic arthritis. or a referral would be made for physical or occupational therapy. infectious arthritis. These signs and symptoms are highly suggestive of a chronic systemic inflammatory process.Orientation Feedback for Rheumatoid Arthritis In evaluating case performance. cardiovascular. more recently. To prevent deformity and loss of joint function. an infectious process. and tender wrist. and effective approach to diagnosis would include performing an appropriate physical examination (including extremities. It is important to manage the acute phase of the disease and to address the long-term care of the patient in this case. She developed generalized aches and morning joint stiffness during the past 8 weeks and. and an erythrocyte sedimentation rate or C-reactive protein test. The following descriptions are meant to serve as examples of actions that would add to. crystals. sequencing. skin. Concomitant administration of a disease-modifying antirheumatic drug (DMARDs). systemic lupus erythematosus (SLE). as well as bilateral knee swelling.

Although they would temporarily relieve pain when administered in high doses. In this case simulation. Therefore. a matter of hours or days. This illustrates the importance of allowing sufficient time for the patient to respond to treatment and emphasizes monitoring and long-term management. Treatment with salicylates would also be considered suboptimal management in this case. when NSAID or corticosteroid treatment is initiated. there are other agents with fewer toxic side effects that would be better treatment options. weeks. physical exam. Examples of additional tests and treatments that could be ordered but would be neither useful nor harmful to the patient include: Chlamydia trachomatis tests Neisseria gonorrhoeae tests Antibody. this scenario runs for a longer period of time. the patient regularly reports both joint and systemic improvements. and improving joint function. Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and add no useful information to that available through history. Examples of poor management would include failure to order any physical examination or failure to treat rheumatoid arthritis. anti-single-stranded DNA Thyroid studies Urinalysis Uric acid. serum Examples of suboptimal management of this case would include delay in diagnosis or treatment. and other relatively noninvasive laboratory tests include: Arthroscopy Synovial biopsy While many case scenarios run for a relatively short period of simulated time.preventing or slowing joint damage. ordering a rheumatology consult or additional monitoring is appropriate but optional during the timeframe of this simulation. or treatment with NSAIDS or corticosteroids alone. . Initial NSAID or corticosteroid treatment is essential to provide interim symptom relief while the selected DMARD takes effect.

The patient has had recurrent nosebleeds during the past 24 hours. efficient.Orientation Feedback for Acute Immune Thrombocytopenic Purpura (ITP) In evaluating case performance. without a recent history of history of diarrhea or abdominal pain. . are self-limited. There is no lymphadenopathy or splenomegaly. Physical examination shows blood oozing slowly from the right naris and a petechial rash on the face. The following descriptions are meant to serve as examples of actions that would add to. Other acceptable treatment alternatives include administration of corticosteroids or administration of IV Rho(D) immune globulin (after verifying that the patient is Rh positive). the patient’s platelet count should be monitored through repeat CBCs. and ordering a complete blood count (CBC). As in many cases. Since serious bleeding in children with ITP is rare. The remainder of the physical examination is unremarkable. Intramuscular injections are not optimal in this case because of the patient’s low platelet count. a 5-year-old boy is brought to the emergency department by his mother because of recurrent nosebleeds. The computer-based case simulation database contains thousands of possible tests and treatments. In addition. arms. and legs. In this case. In this case. Therefore. sequencing. chest/lung. timing. the co-occurrence of bleeding and rash. the recurrent nature of the nosebleeds. cardiovascular. at this point. and the antecedent viral illness necessitate further diagnostic evaluation and appropriate treatment. and location are considered. and require no diagnostic work-up or intervention. and skin or extremities examinations). suggests the possibility of a coagulation disorder. Regardless of the ITP treatment option. along with the recent history of upper respiratory tract infection. Initially the differential diagnosis is narrow. continued monitoring is an important consideration in this case. Most cases of nosebleed last a short time. The bleeding stops after applying direct pressure. HEENT/neck. monitoring. The patient is frightened and crying. or have no effect on an examinee's score for this case. would still seem most consistent with a hematologic process. the diagnosis of acute ITP can be made. Once the low platelet count is discovered and the peripheral smear reviewed. a reticulocyte count should be ordered to exclude other thrombocytopenic disorders such as thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS). He also has a red rash and a recent history of upper respiratory tract infection. observation and monitoring of the platelet count would be acceptable management. The patient's illness. therapy. controlling the oozing blood by ordering direct pressure to the nose. subtract from. it is not feasible to list every action that might affect an examinee's score. and effective approach would include performing an appropriate physical (including lymph node. the comprehensive history broadens the differential. Alternatively. An optimal. however. however. administration of intravenous immunoglobulin (IVIG) is equally acceptable. abdominal. The onset of bleeding and a rash. the domains of diagnosis (including physical exam and appropriate diagnostic tests).

Examples of additional tests and treatments that might be ordered but would be neither useful nor harmful to the patient management include: Antibody. DNA Examples of suboptimal management of this case would include delay in ordering the CBC or failure to treat the nosebleed. plasma Polymerase chain reaction. hepatitis C Anticoagulant. HIV. Examples of poor management would include failure to order a CBC in order to identify the thrombocytopenia or failure to monitor the platelet count.Note that the benefit of measuring platelet antibodies remains debatable as does performing bone marrow aspirate/biopsy. lupus. antinuclear Antibody. antiphospholipid Antibody. Examples of treatments that would subject the patient to unnecessary discomfort or risk and add no real benefit to this patient include: Antiplatelet therapy Intramuscular medications ICU admission Nasal cauterization Transfusion with whole blood or packed red blood cells .

There is no history of drug use. The absence of systemic symptoms such as fever or malaise. efficient. the differential diagnosis is broad. or have no effect on an examinee's score for this case. Therefore. The patient’s recreational pursuit of camping may be of etiologic significance. Examples of additional tests and treatments that could be ordered but would be neither useful nor harmful to the patient include: Complete blood count Stool white blood cells . a 25-year-old man comes to the office because of diarrhea and abdominal cramps. Monitoring is not important in this case. timing. although it may be essential in other cases. or tenesmus reduces the likelihood of invasive gastrointestinal infection or inflammatory bowel disease. Physical examination shows no volume depletion. The computer-based case simulation database contains thousands of possible tests and treatments. The patient does not appear ill and the abdomen is soft and nontender. and the lack of response to over-the-counter medications warrant a diagnostic evaluation and appropriate treatment. Stool is negative for gross or occult blood. The patient's illness. subtract from. monitoring. recent hospitalizations. the domains of diagnosis (including physical exam and appropriate diagnostic tests). and location are considered. 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. Most instances of diarrhea are of short duration and are self-limited and require no diagnostic work-up. watery stools per day. or recent use of antibiotics to suggest Clostridium difficile-induced enterocolitis. antimotility agents can be used for symptomatic relief pending test results. when he began to have four to six loose. and stool Giardia antigen or stool for ova and parasites. The presence of nocturnal symptoms and weight loss indicates that the problem may be more than a purely functional gastrointestinal motility disorder. therapy. and effective approach would include (1) performing an appropriate physical that includes abdominal and rectal examinations. From the chief complaint. at this point. the comprehensive history narrows the differential. In this case. the weight loss. In this case. Diarrhea lasting 1 to 4 weeks is usually infectious in origin. blood in the stool. sequencing.Orientation Feedback for Giardiasis In evaluating case performance. would seem most consistent with an acute or subacute infectious process. however. The patient was well until 3 weeks previously. In the absence of fever or severe dysentery. however. An optimal. and the remainder of the physical examination is unremarkable. and (3) treating with oral metronidazole after confirming the diagnosis of giardiasis. there is no history of other infectious exposures. (2) ordering diagnostic testing with a stool culture. the duration of symptoms.

and then treating with second line antibiotics such as furazolindone. Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and add no useful information to that available through history. Examples of poor management would include failure to order any physical examination or failure to treat giardiasis. Examples of suboptimal management of this case would involve admitting the patient to the hospital or delay in diagnosis or treatment of the giardiasis.Stool for Clostridium difficile Stool for Cryptosporidium Serum electrolytes Sigmoidoscopy Oral electrolyte mixtures An example of an alternative approach that is minimally acceptable would be performing an appropriate physical exam. physical exam. diagnosing giardiasis with a duodenal aspirate or serum Giardia antibody without first attempting to identify the organism in the stool. or paromomycin. nitazoxanide. and other relatively noninvasive laboratory tests include: Upper Endoscopy Colonoscopy Barium studies .

The patient is anxious. and an indistinct S2 with S4 audible at the apex. however. She has a history of hypertension for the past 5 years that is being appropriately treated with medication. and location are considered. The patient is experiencing sharp. Once stable. and long history of hypertension are highly suggestive of the diagnosis of ascending aortic dissection. therapy. She is now short of breath and mildly nauseated. cough. or MRI of the chest) is needed. In this case. Cardiovascular examination reveals a prominent and sustained apical impulse. subtract from. Physical examination shows hypertension and tachycardia with bounding central and peripheral pulses. a 65-year-old woman comes to the emergency department complaining of chest pain. From the chief complaint. aortic murmur. Stabilizing the patient with intravenous (IV) beta blocker or an IV antihypertensive agent administration to reduce blood pressure. it is not feasible to list every action that might affect an examinee's score. the differential diagnosis is broad. Therefore. would seem most consistent with a coronary or aortic abnormality with associated aortic regurgitation. ordering a 12-lead electrocardiogram and a portable chest x-ray. chills. some form of chest imaging that would reveal an aortic dissection (including CT of the chest with contrast. The patient's illness. a complete blood count (CBC) to look for signs of anemia and infection. left-sided chest pain that radiates to her left jaw and to her back. or have no effect on an examinee's score for this case. efficient. and in mild distress from chest pain. The following descriptions are meant to serve as examples of actions that would add to. the domains of diagnosis (including physical exam and appropriate diagnostic tests). serum creatine phosphokinase or serum troponin I (cardiac enzymes) to rule out myocardial compromise. The diagnostic workup should also include blood tests for serum creatinine (basic metabolic profile or complete metabolic profile) to assess kidney function. The patient’s cardiovascular status should be monitored with a cardiac monitor or by ordering repeat vital signs. monitoring. and a grade 2/6 diastolic decrescendo murmur heard best at the left sternal border. electrolytes to check sodium and potassium levels. or pleural rub suggests that the problem is not an infectious pulmonary process. sequencing. the comprehensive history narrows the differential. In this case. a d-Dimer to rule out a . An optimal. The remainder of the physical examination is unremarkable. and effective approach would include performing a targeted physical examination (including cardiovascular and chest/lung examinations). timing. The computer-based case simulation database contains thousands of possible tests and treatments. widened pulse pressure. There is no history of any previous episodes of chest pain either at rest or on exertion. transesophageal echocardiogram (TEE). The absence of fever. CT of the chest without contrast. The pain began abruptly 45 minutes before coming to the hospital. diaphoretic. at this point. echocardiogram. HEENT examination shows grade II arteriovenous nicking on funduscopic examination. the sudden onset of radiating chest pain along with the bounding pulses. and IV narcotic analgesic administration to alleviate pain is important.Orientation Feedback for Ascending Aortic Dissection In evaluating case performance. Some measure of oxygen saturation is also indicated.

or failure to order surgical intervention. Some measure of oxygen saturation is also indicated. e. treatments. An optimal approach would include completing the above diagnostic and management actions as quickly as possible. Once the ascending aortic dissection is discovered and aortic root involvement confirmed. Examples of poor management would include failure to order any physical examination. neglecting to order indicated blood tests. i. or would add no useful information to that available through safer or less invasive means. It would be suboptimal to order anything unnecessary that would waste time. or a delay in diagnosis or treatment.pulmonary embolus. optimal treatment should include either open heart surgery. or general surgery consult. Examples of additional tests. right and left heart Antibiotics Suboptimal management of this case would include ordering a complete physical examination or additional PE components that would add no relevant information. Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk. even if the test or procedure is not invasive or risky. failure to administer an antihypertensive agent. and a type and crossmatch blood. lung scan.. thoracotomy or thoracic surgery. during the first 2 hours of simulated time. include: Changing the location to the outpatient office or sending the patient home Chest tube Exercise electrocardiogram Heparin Laparotomy Needle thoracostomy Stress echocardiogram Thrombolytics Warfarin . In this acute presentation. timing is critically important.e. administering an IV antihypertensive without a beta blocker. or actions that could be ordered but would be neither useful nor harmful to the patient include: Admitting the patient to the inpatient ward or intensive care unit Angiocardiography. failure to order an imaging study that would reveal the dissection.g.